中医叙事医学的反思与再现

中医领域的叙事医学研究目前正蓬勃发展,但叙事实践的理论基础不充分、缺乏中医叙事特色。为解决叙事医学研究历史跨度不足、古代医籍与现今临证叙事关系不清晰的问题,在诠释学视域下考察中医叙事,发现各家理论和临证诊疗均具有浓厚的诠释学特质、理论发展和临证实践均属于诠释过程,符合叙事医学的“反思”与“再现”。在此基础上,叙事医学的理论研究可归纳为三个反思与再现的阶段,分别以《黄帝内经》、各家学说、临证实践为叙事主体,具有各自的叙事阵地和叙事方式。

杏苑

五倍子性味酸、涩、寒。归肺、大肠、肾经。临床多用于肺虚久咳、久泻等。笔者用五倍子外敷肚脐治疗小儿遗尿,效果颇佳。 取五倍子10g,研细为末,分3份,取1份用醋调成膏状,其余备用。用新洁尔灭消毒患儿脐部,取消毒纱布一块,纱布一面涂上药膏,敷于肚脐处,外加胶布固定。每3日更换药膏1次,9日为1疗程。 患儿宋××,女,6岁。

Common misconceptions about 5-aminosalicylates and thiopurines in inflammatory bowel disease

Misconceptions are common in the care of patients with inflammatory bowel disease(IBD).In this paper,we state the most commonly found misconceptions in clinical practice and deal with the use of 5-aminosalicylates and thiopurines,to review the related scientificevidence,and make appropriate recommendations.Prevention of errors needs knowledge to avoid making such errors through ignorance.However,the amount of knowledge is increasing so quickly that one new danger is an overabundance of information.IBD is a model of a very complex disease and our goal with this review is to summarize the key evidence for the most common daily clinical problems.With regard to the use of 5-aminosalicylates,the best practice may to be consider abandoning the use of these drugs in patients withsmall bowel Crohn's disease.The combined approach with oral plus topical 5-aminosalicylates should be the first-line therapy in patients with active ulcerative colitis;once-daily treatment should be offered as a first choice regimen due to its better compliance and higher efficacy.With regard to thiopurines,they seem to be as effective in ulcerative colitis as in Crohn's disease.Underdosing of thiopurines is a form of undertreatment.Thiopurines should probably be continued indefinitely because their withdrawal is associated with a high risk of relapse.Mercaptopurine is a safe alternative in patients with digestive intolerance or hepatotoxicity due to azathioprine.Finally,thiopurine methyltransferase(TPMT)screening cannot substitute for regular monitoring because the majority of cases of myelotoxicity are not TPMT-related.

The concept of narrative evidence-based medicine and shared decision-making in traditional Chinese medical practice

For the explosive development of emerging diagnostic and therapeutic technologies brought by the advancement of precision medicine strategy, shared decision-making could improve the quality of clinical decision-making and promote the transformation of clinical research evidence in TCM. Paying attention to patients＇ narrative needs and strengthening medical humanistic concerns could improve clinical outcome and patient satisfaction. We described the origins and development of evidence-based medicine, narrative medicine and shared decision-making, and analyzed the existing problems in TCM clinical decision-making. Further, we put forward the model of shared decision-making between clinicians and patients under the guidance of narrative evidence-based medicine concepts and methods.

Full process of recommendation formulation for clinical practice guidelines:Taking World Federation of Acupuncture-Moxibustion Societies Clinical Practice Guideline on Acupuncture and Moxibustion:Allergic Rhinitis as an example

The formulation of recommendations is a crucial step in the development of clinical practice guidelines,which requires tools provided by the GRADE methodology.These tools include the evidence quality assessment tool,the evidence summary tool,and the evidence-to-decision(EtD)framework.Although there is a methodologically guided standard pathway for formulating recommendations in clinical practice guidelines,it remains unclear how to translate this theoretical pathway into the practical process for formulating recommendations and what the specific steps in this process entail.Therefore,this paper takes the World Federation of Acupuncture-Moxibustion Societies Clinical Practice Guidelines on Acupuncture and Moxibustion:Allergic Rhinitis as an example to detail the full process of formulating recommendations and summaries it into a three-step method.Step one:Collect original materials from different sources to create EtD table.Step two:Distribute and collect EtD table,and preliminarily gather the recommendation voting results.Step three:Organize"salami-slicing pattern"guideline development group consensus meeting to formulate recommendations.The three-step method for formulating recommendations in clinical practice guidelines fully utilizes the GRADE EtD table to provide guideline development group with decision-making foundation and reference from multiple dimensions,including the importance of clinical questions,balance of benefits and harms,quality of evidence,resource required,values and preferences,health equity,acceptability,and feasibility.This approach enhances the scientific and practical nature of guideline recommendations.This paper provides a standard operating procedure to formulate recommendations for the incoming clinical practice guidelines,which aims to establish a standard pathway for the formulation of acupuncture clinical practice guideline recommendations.

Evidence-based clinical practice guidelines for acupuncture-moxibustion treatment of scapulohumeral periarthritis

The aim of this study was to establish clinical practice guidelines for acupuncture-moxibustion by retrieving relevant literature and adopting the best current national and international evidence, according to experts＇ experience and patients＇ values. This was achieved using the Grade of Recommendations Assessment, Development and Evaluation（GRADE） system combined with a wide range of national experts＇ consensus, in order to provide reliable evidence for acupuncture-moxibustion treatment of scapulohumeral periarthritis, and to ensure the safety and effectiveness of the treatment.