我们感谢谁是"惊人的"脑损伤幸存者在弗雷明汉，MA或访问通过斯波尔丁康复医院的门诊服务支援小组的成员参与的研究，导致本文的14个脑损伤患者。脑损伤协会马萨诸塞州，马萨诸塞州康复委员会州卫生损伤计划，并为卫生政策的质量和施耐德学院卫生保健研究机构在海勒学校社会政策，资金和其他支持的研究提供了和管理，布兰代斯大学，通过在卫生服务研究和政策分析的博士后培训奖学金。

1。简介: 在路口的质量鸿沟，2001年医学研究所（IOM）对质量和卫生保健的报告，有针对性的改进的一个地区以病人为中心，或病人的疾病和保健的经验。病人为中心的一个重要方面是尊重病人的价值观，偏好和表达的需要。然而，国际移民组织的报告中没有指定供应商可以如何采取步骤，以了解病人的价值观，喜好，和表达的需要。它也没有提供有关病人的角度来看，未来的了解如何转化，以提高临床护理质量的指导。它是在临床上遇到，我们必须概念化和适用于病人"的价值观，喜好，过路的质量和卫生保健的鸿沟，并表示需要学习。医学模式指导我们的卫生保健实践，导致供应商来治疗疾病。公平的过程中成立的医疗模式，可以帮助我们给病人治病。 要实现以人为本的护理，临床医生需要了解病人的生命和他们的工作，坚持在家中和他们的社区治疗的建议。医疗模式，不包括环境，患者必须采取行动，医治。它不包括对护理质量和他们的治疗过程中病人的角度来看。通常的医疗模式是一种以病人为中心的护理的挑战。 从病人的角度来看，质量是不是一个简单的概念，但最好在五个方面理解:在生活质量方面的技术成果;健康高效路线的决策效率;设施和便利，信息和情感上的支持（关系）;和整体病人的满意度（Chilingerian 2004年）。这五管齐下，从病人的角度来看，质量的概念是在图1所示:星的质量，以病人为中心的观点。 <img src="/files/ftp_upload/2342/2342fig1.jpg" alt="图1" /> 图1星的质量，以病人为中心的观点。 （2004年Chilingerian） 未考虑在医疗成果为重点，而不考虑实现这些成果是至关重要的进程，从病人的角度来看结果的质量。 Kim和Mauborgne（1997），他们在企业公平的进程中的开创性的研究，指出，人照顾有关的成果，但他们可能用来产生这些成果的过程放在更重要的，他们想要的感觉，听到他们的观点是。 Kim和Mauborgne的19家公司的研究发现，一个组织过程，态度，行为和性能之间的直接联系。所示，Kim和Mauborgne认为在形式公平的进程中，程序正义的信任和承诺，自愿合作，并超出了预期。 <img src="/files/ftp_upload/2342/2342fig2.jpg" alt="图2" /> 图2:性能（金＆Mauborgne，1997年，与哈佛商学院出版社的许可使用） 的两个互补的路径。 公正的程序和临床护理在临床护理中，​​公平的过程发生在病人提供者之间的相互作用。从概念上讲，公平的进程中，打开门把病人的发展中国家卫生保健的目标和战略工作的专业知识。范德Heyden 等 （2005）描述公平的进程中的一些关键要素。公平的进程中从事的护理过程中，分析病人的情况导致一个问题的框架的患者，如在临床医生和患者的工作，以探索和狭窄的诊断问题，治疗，及治疗方法的清单，解释的决定的理由，设置有关病人提供者的角色和职责的期望，并实现了与朝预后评价和相互学习的眼睛护理计划。 病人提供者之间的相互作用，公平的进程中建立关系和信任。公平的过程，而不是线性圆形，深的参与，探索和解释，可能同时出现在任何顺序为病人和服务提供者共同探讨挑战，并找出解决办法。每个交互成为一个相互学习和参与的新机会。 公平的过程模型侧重于保健的关系。在此模型中，"正常"的质量改进方案有更多时间与病人，例如绩效奖励的边际变化并不一定有帮助。相反，改善供应商与病人的关系，并带入不同的专业知识的互动是可赚取差价。图3的五行，公平过程中的病人提供交互，提供了一个公平的过程在诊所的模式人照顾。 <img src="/files/ftp_upload/2342/2342fig3.jpg" alt="图3" /> 图3的病人提供交互（范德Heyden，布隆德尔，Carlock，2005年，Chilingerian 2006年;洛伦茨，2007年）的五要素公平的过程 。 运用公平的进程中，为脑损伤患者的护理:鼓励对话和接触有共650大脑有关的疾病，它们共同影响更长远的医疗费用和住院比几乎所有其他合并疾病（博伊尔2001年）50万美国人每年帐户。获得性脑损伤是任何损伤的大脑在认知，身体，情感，或独立运作（雪利酒2006）恶化的结果。创伤性脑损伤（TBI）是由钝力外伤，或电击头部引起的伤害。在美国，每年有140万新TBIS诊断在紧急情况下，并承担每年48美元至56美元亿美元（彰等，2004）成本。据估计，有530万美国人的生活造成脑外伤（约2％的人口）的残疾人，和80000至90000人加入他们的人数每年（彰等人，2005 年彰等人，2004年）。另有500万美国人患有脑损伤，由于中风（ACBIS书）。正如图4年发病率（TBI）的，脑外伤的影响越来越多的美国人每年比多发性硬化症，脊髓损伤，艾滋病毒/艾滋病，并结合乳腺癌。 <img src="/files/ftp_upload/2342/2342fig4.jpg" alt="图4" /> 图4年发病率（TBI） 脑损伤可影响幸存者的生活的许多方面，从认知机能，情感，心理，和物理福祉，自尊，能力，以工作和参与的社会，社会经济地位，并认识自我（张伯伦2006年，美国国立卫生研究院，1998年）。任何脑损伤时，即使确诊为"温和的"，表示，任何是短暂的意识丧失，可能有严重，长期的后果。例如，脑损伤幸存者可能有所减缓处理速度，在他们的大脑，麻烦重点或集中，短期记忆问题，这些挑战变得容易受挫。他们可能会很容易疲劳，影响他们的工作能力。通信问题，包括失语，可能是一个问题（ 莱文等人，2007年）。通常情况下，患者看起来是一样的，以往任何时候都内，它们是不同的，和他们的伤害是无形的。图5在冰上的运行提供了一个例子是什么样的生活与脑损伤从参与者的角度如下: <img src="/files/ftp_upload/2342/2342fig5.jpg" alt="图5" /> 图5，就像上运行冰从临床角度讲，脑损伤可能会造成混淆。有没有俗套的解决方案，并每个病人的伤害和治疗是不同的。质量意味着调整治疗计划，以个人。然而，脑损伤的认知挑战可能会影响病人的能力，以反映他们的情况，请记住重要的信息，并在临床上进行通信。这些挑战需要一个创造性的方法，了解脑损伤患者的角度对他们的疾病和保健的经验。问颅脑损伤患者，以反映他们的生活，他们的情况下拍摄照片，并使用他们的照片，来传达他们的的挑战和优势，是在行动过程公平的一个例子。 使用可视化的方法来了解生活经验可视化方法在公共卫生环境（2009年洛伦兹和科尔布;王和伯里斯1997年）的应用越来越广泛使用和接受。可视化方法通常用于案例研究的研究（尹2003年），和疾病的经验调查（洛伦茨2010B; Berland 2007年，2003年Radley和泰勒;丰富，戈登，并Chalfen 2000）。作为社会科学的数据接受的视觉形象，包括图纸，照片，视频，图表，地图（Guillemin 2004 年，奥克利等人1995年）。视觉的方法，在支持与患者沟通减缓认知处理速度和失语（ 莱文等人2007年）。他们可以鼓励患者探索和唤起的情绪，从而补充的临床方法，使用的统计数据，并鼓励提高他们的健康和卫生保健病人参与（Entwistle，Tritter，和Calnan 2002年），测量他们的问题。照片引出和photovoice如参与视觉的方法，让病人临床带入他们的专业知识，并教医生（洛伦茨2010A; Chalfen和丰富的2004年）。 有些人认为，患者的经验性知识必然是有限的，应该不是Be将医疗知识（2003年之前）相提并论。然而，疾病和疾病的专业的理解也有限，需要考虑患者的理解以及他们的健康和卫生保健。使用参与性的可视化方法是一种方法，产生更广泛的背景下，在临床护理嵌套的认识，并制定一个知识共享的机构，整合了医生和患者（2009年Lorenz和科尔布）的专业知识。 例如，神经心理学家乔治Prigatano（1989）长期以来一直呼吁临床医生了解他们的病人经历，并认为，发展中国家从现实生活隔离病人的治疗计划，可能会削弱该计划的相关性。在工作​​与大脑受伤的病人，是在要求有自己的视频录音Prigatano执行重建任务，要求她画一个图片如何，她感觉她和她的伤害。的愤怒和不安创建此图，在图4，允许病人讨论她的恐惧和建立一种积极的关系，与医生Prigatano的治疗，部分灵感这个视频期刊论文中所描述的研究和程序。 <img src="/files/ftp_upload/2342/2342fig6.jpg" alt="图6" /> 图6:由脑损伤幸存者。由牛津大学出版社，Page.112，图7-1许可使用的"脑损伤后的赤字意识:临床和理论问题" <a href="http://www.oup.com">。</a> www.oup由George P. Prigatano和Daniel L. Schacter（1991）编辑<a href="http://www.oup.com">COM</a> 。 2。病例报告: 本文所示的程序与14之间的20至60岁的成人脑损伤幸存者，2006年和2007年之间:6颅脑损伤患者的访问通过斯波尔丁康复医院门诊服务，并与脑损伤幸存者支持的8名成员组。 斯波尔丁康复医院参与者:所有六个有创伤性脑损伤和工作洛伦茨博士之前，大约一年受伤。三是男性，三​​是女性。一名男性和两名女性，年龄在20至26岁，一雄一雌，年龄在40至50岁，和一名男性，年龄58岁。一些希望有关复苏研究的时间事先能力;两个已经回到他们以前的教育或工作，如果在不同的能力。 这项研究的临床合作者，在斯波尔丁康复医院的高级语言病理学家，建议使用修改功能量表的认知水平作为我们的纳入/排除标准（哈根，1997年）（修订）兰乔斯洛杉矶吾友参与者分数。规模定义从"无反应"（第一阶段）"有目的的和适当的"（X）十年的认知功能水平。医生通常使用独立结转库存预计为参与切断第七级别的诊断。简单地说，在认知水平七人: <ol class="lalpha"><li>面向的人，他们说的地方，他们在保持; </li><li>最低限度的援助至少30分钟，参加任务; </li><li>新的学习需要最少的监督; </li><li>展示的新的学习结转; </li><li>发起和开展的步骤，以完成人们熟悉的个人和家庭日常，但可能有浅记得他们一直在做什么，并要求在日常家居及社区活动的最小安全监督。 </li></ol>图7显示了10兰乔斯洛杉矶吾友修功能量表的认知水平（修订本），并介绍了它们。 <img src="/files/ftp_upload/2342/2342fig7.jpg" alt="图7" /> 图7。兰乔斯洛杉矶吾友认知功能量表（修订）（哈根，1997年）。 支持组的参与者:中两名受伤的项目开始前三年或四年，4人受伤8年和17年的研究之前，两人受伤前25年以上。六有创伤性脑损伤中生存下来，两个幸存下来脑瘤。参加者年龄从40岁到60岁不等，5个是妇女和三个是男性。所有生活与脑损伤的残疾。 为支持集团的参与者，纳入/排除标准包括: <ol class="lalpha"><li>在支持组的成员; </li><li>参加有趣的; </li><li>能力和意愿，要坚持活动的道德准则; </li><li>承诺出席所有支持组photovoice会议的能力和意愿。 </li></ol> 3。程序: Photovoice已several步骤，如在图8 Photovoice路径所示。个别病人，医生将使用的前几个步骤。与支持团体，所有步骤都可以使用。 <img src="/files/ftp_upload/2342/2342fig8.jpg" alt="图8" /> 图8。Photovoice路径（洛伦茨，2010A）。 步骤1:从事病人，成为视觉研究员<img src="/files/ftp_upload/2342/2342fig9.jpg" alt="图9" /> 学习是一个视觉研究员图标图9。 这一步的目标是从事拍照转让的病人，确保病人明白了自己的生活视觉研究员的道德参数。 解释的分配。病人是免费的，同意参加或不。讨论伦理方面的考虑:未经其许可的情况下的其他人没有图片，未经主人的许可，物业没有照片，没有非法活动的图片，在妥协的情况下没有人的照片。讨论病人的问题，或回答的问题，照片或其他视觉。样题包括: <ol><li>是什么样子的生活与脑损伤？ </li><li>什么在我的生命或社会的帮助，我在我的脑损伤的恢复？ </li><li>有什么放慢了我的脑损伤恢复？ </li><li>我想告诉其他人的生活与脑损伤，什么？ </li><li>是我的生命，现在从之前如何如何不同？什么是更好吗？更糟糕的是什么？ </li><li>我对未来有什么希望？什么可以帮我那里吗？ </li></ol>解释说，病人可以在现有的照片或从一本杂志的图片带来了新的照片，使打印或数字文件，或创建一个新的绘图，拼贴，或其他艺术品，将回答转让问题或问题从病人的角度来看。 要求至少两个图像:一个东西在人的生活产生积极的和负面的东西之一。 解释说，图像可以是一个具体的问题（如一堆文书工作或要填写的表格），或为感情的比喻（如从以前的自我，或从其他人的感觉断开）。讨论每个例如，在图提供了一个具体主题的10样品的照片，和图11的比喻为感情的样品照片。参见图5的一个隐喻的形象样本。 <img src="/files/ftp_upload/2342/2342fig10.jpg" alt="图10" /> 图10样品的具体主题的照片。 <img src="/files/ftp_upload/2342/2342fig11.jpg" alt="图11" /> 图11。样品比喻为感情的照片（洛伦茨，2010C） 。 鼓励病人使用一个笔记本，记录照片的主题和原因，他们正在一个特定的照片。 角色扮演拍照活动。假装自己是摄影的主题。请耐心地解释为什么他们拍照，他们为什么要采取你的照片。角色扮演需要的好几倍。 如图12图标的照片采取转让，病人将他或她的自己，拍照或以其他方式产生两个图像（一个正极和一个负极），在下届会议讨论。 <img src="/files/ftp_upload/2342/2342fig12.jpg" alt="图12" /> 图12照片，采取转让图标。 第3步讨论拍照的分配和图像<img src="/files/ftp_upload/2342/2342fig13.jpg" alt="图13" /> 图13讨论步骤的图示 。 询问病人是什么样子拍照。很容易吗？是很难吗？没有人问，为什么他或她拍照？病人要求任何人的许可，他们的照片？ 让患者向您展示他或她的两个图像。看看每一个小心（贝克尔，1986）。你看到了什么？你认为该图像可能会意味着什么？ 询问病人为什么S /或选定的图像。他们是什么意思他呢？他们表示，以她？ 你自己的角度考虑图像。你看到在病人服用的打算图像吗？在尊重和好奇的方式，讨论你所看到的以及的。照亮图像哪些优势？什么样的弱点是什么？ 讨论可能的治疗目标图像提出。讨论可能的策略，以帮助病人达到这个目标。 考虑艾斯克吴病人带来两个图像或在下届会议。回答相机的可能的问题包括: <ol><li>你怎么觉得这个目标一旦你回家吗？ </li><li>是什么帮助你朝着你的目标的进展情况？ </li><li>是什么阻碍你的进步呢？ </li><li>有哪些策略可以帮助你达到你的目标吗？ </li></ol>如果考虑和讨论在临床上的图像的过程中出现的，以支持建立一个治疗联盟，继续进行步骤2和3。另外，作为一个偶然的方式了解病人面临的问题和积极的事情，在他或​​她的生活以及的，随着时间的推移。 4。结论: 询问患者进入临床设置他们的生活带来视觉可以帮助照亮在临床知识方面的差距，与慢性疾病，如脑损伤患者生活建立更好的治疗关系，并确定以病人为中心的目标和治愈的可能性。此视频文章中说明的过程中可以使用<ol class="lalpha"><li>慢性病患者生活工作的初级保健医生; </li><li>语言病理学家，职业治疗师，物理治疗师，和护士获得性脑损伤的幸存者和其他工作，如康复医师; </li><li>神经学家，神经心理学家，以及其他潜在的慢性疾病，如获得性脑损伤患者生活工作; </li><li>心理学家和其他工作与生活患有精神病或其他类似的慢性疾病的人; </li><li>上文所述的病人和他们的家庭成员或其他照顾者支持团体的领导人。 </li></ol>虽然摄影可以作为一个"颠覆性技术"挑战的信念和假设，它可能成为一个新的临床方法。患者帐户，可以看到一个更便宜，更简单的方法来确定以及患者和医生是如何满足他们的目标呢？

<ol>
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C., Mauborgne, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fair+process:+Managing+in+the+knowledge+economy.">Fair process: Managing in the knowledge economy.</a> Harvard Business Review. 75, 65-75 (1997).</li><li>Langlois, J. A., Rutland-Brown, W., Thomas, K. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+incidence+of+traumatic+brain+injury+among+children+in+the+United+States+-+Differences+by+race.">The incidence of traumatic brain injury among children in the United States - Differences by race.</a> Journal of Head Trauma Rehabilitation. 20, 229-238 (2005).</li><li>Langlois, J. A., Rutland-Brown, W., Thomas, K. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Traumatic brain injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. , (2004).</li><li>Levin, T., Scott, B. M., Borders, B., Hurt, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aphasia+talks:+Photography+as+a+means+of+communication,+self-expression+and+empowerment+in+persons+with+aphasia.">Aphasia talks: Photography as a means of communication, self-expression and empowerment in persons with aphasia.</a> Topics in Stroke Rehabilitation. 14, 72-84 (2007).</li><li>Lorenz, L. 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S., Kolb, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Doing+your+own+PhotoVoice+project:+A+guide.">Doing your own PhotoVoice project: A guide.</a> Brainline [Internet]. , (2009).</li><li>Lorenz, L. 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N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Health+and+cancer+prevention:+Knowledge+and+beliefs+of+children+and+young+people.">Health and cancer prevention: Knowledge and beliefs of children and young people.</a> British Medical Journal. 310, 1029-1033 (1995).</li><li>Prigatano, G. P., Schacter, D. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Awareness of deficit after brain injury: Clinical and theoretical issues. , (1991).</li><li>Prigatano, G. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Work,+love,+and+play+after+traumatic+brain+injury.">Work, love, and play after traumatic brain injury.</a> Bulletin of the Menninger Clinic. 53, 414-431 (1989).</li><li>Prior, L. B. e. l. i. e. f. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=knowledge+and+expertise:+the+emergence+of+the+lay+expert+in+medical+sociology.">knowledge and expertise: the emergence of the lay expert in medical sociology.</a> Sociology of Health &#38; Illness. 25, 41-57 (2003).</li><li>Radley, A., Taylor, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Images+of+recovery:+a+photo-elicitation+study+on+the+hospital+ward.">Images of recovery: a photo-elicitation study on the hospital ward.</a> Qualitative Health Research. 13, 77-99 (2003).</li><li>Heyden, L. B. V. a. n. d. e. r., Blondel, C., Carlock, R. 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A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Photovoice:+Concept,+methodology,+and+use+for+participatory+needs+assessment.">Photovoice: Concept, methodology, and use for participatory needs assessment.</a> Health Education &#38; Behavior. 24, 369-387 (1997).</li><li>Yin, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Case study research, design and methods. , (2003).</li></ol>

第一作者提供photovoice和通过医疗学校及其他教育场所的照片引出的培训。第二作者没有透露。

受访者成为合作伙伴，并发挥作用，只有病人才能真正知道是什么样的生活与脑损伤和经验相关的护理的"专家"在临床上的作用时，他们的生活经验是寻求。此外，许多脑损伤幸存者的卫生保健的目标似乎愈合，不恢复。恢复意味着希望恢复到受伤前的状态。刚受伤的病人，可能是希望从他们的伤势恢复，但长期的幸存者接受，他们将无法返回到其之前的状态。他们看到愈合的认知，身体，情绪，甚至精神（洛伦茨2010A）。他们认为，他们不断进步随着时间的推移，他们的伤害，甚至多年后。在谈到自己的生活照片，可以帮助患者和医生，以确定以人为本，关注领域，承认并赞赏患者随着时间的推移进展。 公平的过程，应用于临床护理病人的深入参与，探索，他们的经验可以改进的方式，了解所有的临床决定的理由，并接受自己的角色和责任。公平的过程，激活患者坚持康复战略，并采取行动，在他们的治疗进展的动力。当供应商公平的进程中，临床护理，病人和服务提供者的期望和目标可以更好地保持一致。这张照片成为互动的焦点，并为病人从事的专业，以及在探索的经验和建立关系。治疗关系可能得到改善。此外，根据Kim和Mauborgne模型，产生的态度和行为的改变，可能会导致更好的成果。 公平的过程，在临床上的互动的电源可能会变得更加平衡，如病人感到，他们正在聆听。讨论的照片，和它们的含义，可以帮助患者成为的解决方案，不只是问题的一部分。使用相机是不是唯一的途径，以实现公平的过程，它不是为每一个病人或每一个临床医生的做法。它是一个工具和方法，从事病人，提高沟通困难的情况下，实现以人为本的护理。

using visual and narrative methods to achieve fair process in clinical care

医学研究所有针对性地为病人为中心的质量改善的重要领域。病人为中心的一个主要方面是尊重病人的价值观，偏好和表达的需要。然而，缺乏具体的办法来获得这种理解和翻译，在临床上的优质医护服务。从病人的角度看质量不是一个简单的概念，但最好是在五个方面理解:技术成果;决策效率;设施和便利，信息和情感上的支持;和整体病人的满意度。不考虑从这一医疗成果为重点五管齐下的角度来看结果的质量，不考虑中央从病人的角度来看，质量和进程取得了良好的成果至关重要。在本文中，我们认为在临床上的应用公平过程中的概念。公平的过程，涉及使用一种合作的方式探索诊断问题，并与患者的治疗，说明决定的理由，设置有关的角色和职责期望，并实施一项核心计划和正在进行的评估。公平的进程中，打开门，把病人的临床和发展中国家的卫生保健的目标和战略的工作专长。本文提供了一个创新的视觉方法的说明一步一步，被称为photovoice或照片引出，实现公平的过程，在临床工作中获得性脑损伤的幸存者和其他人的生活与慢性健康状况。这种可视化工具和方法在临床上的应用将提高病人供应商的沟通;病人从事作为合作伙伴，在确定挑战，优势，目标和战略，并支持评价随着时间的推移进展。询问患者的临床互动，他们的生活带来的视觉效果，可以帮助照亮在临床知识方面的差距，与慢性疾病，如脑损伤患者生活建立更好的治疗关系，并确定以病人为中心的目标和治愈的可能性。这里说明这个过程可以由医生，工作与生活与慢性疾病，如获得性脑损伤，精神疾病，身体残疾的人（初级保健医生，康复治疗师，神经科，神经心理学家，心理学家，和其他人），艾滋病毒/艾滋病，滥用药物，或创伤后应激，上文所述的病人和他们的家人或照顾者支持团体领导人。

Watch this Scientific Journal Video about Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care at JoVE.com

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

本文说明了一个创​​新的视觉方法（photovoice或照片引出），实现公平的过程，在临床护理与慢性疾病患者生活，照亮了临床知识的空白，打造更好的治疗关系，并确定以病人为中心的目标和治愈的可能性。

利用视觉和叙事方法，以实现公平的进程中，在临床护理

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

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Ethical and Legal Aspects in Nursing

Healthcare Delivery Systems

SCIENTISTS IN ACTION

23.4K 次观看.  Brandeis University. 本文说明了一个创​​新的视觉方法（photovoice或照片引出），实现公平的过程，在临床护理与慢性疾病患者生活，照亮了临床知识的空白，打造更好的治疗关系，并确定以病人为中心的目标和治愈的可能性。

视频: Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

Development of an Audio-based Virtual Gaming Environment to Assist with Navigation Skills in the Blind

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio based cues and set within the context of a video game metaphor, users gather relevant spatial information regarding a building's layout. This allows the user to develop an accurate spatial cognitive map of a large-scale three-dimensional space that can be manipulated for the purposes of a real indoor navigation task. After game play, participants are then assessed on their ability to navigate within the target physical building represented in the game. Preliminary results suggest that early blind users were able to acquire relevant information regarding the spatial layout of a previously unfamiliar building as indexed by their performance on a series of navigation tasks. These tasks included path finding through the virtual and physical building, as well as a series of drop off tasks. We find that the immersive and highly interactive nature of the AbES software appears to greatly engage the blind user to actively explore the virtual environment. Applications of this approach may extend to larger populations of visually impaired individuals.

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind.

基于音频的虚拟游戏环境的发展，以帮助盲人的导航技巧

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio ...

科研

医学

Dynamic Visual Tests to Identify and Quantify Visual Damage and Repair Following Demyelination in Optic Neuritis Patients

In order to follow optic neuritis patients and evaluate the effectiveness of their treatment, a handy, accurate and quantifiable tool is required to assess changes in myelination at the central nervous system (CNS). However, standard measurements, including routine visual tests and MRI scans, are not sensitive enough for this purpose. We present two visual tests addressing dynamic monocular and binocular functions which may closely associate with the extent of myelination along visual pathways. These include Object From Motion (OFM) extraction and Time-constrained stereo protocols. In the OFM test, an array of dots compose an object, by moving the dots within the image rightward while moving the dots outside the image leftward or vice versa. The dot pattern generates a camouflaged object that cannot be detected when the dots are stationary or moving as a whole. Importantly, object recognition is critically dependent on motion perception. In the Time-constrained Stereo protocol, spatially disparate images are presented for a limited length of time, challenging binocular 3-dimensional integration in time. Both tests are appropriate for clinical usage and provide a simple, yet powerful, way to identify and quantify processes of demyelination and remyelination along visual pathways. These protocols may be efficient to diagnose and follow optic neuritis and multiple sclerosis patients.
In the diagnostic process, these protocols may reveal visual deficits that cannot be identified via current standard visual measurements. Moreover, these protocols sensitively identify the basis of the currently unexplained continued visual complaints of patients following recovery of visual acuity. In the longitudinal follow up course, the protocols can be used as a sensitive marker of demyelinating and remyelinating processes along time. These protocols may therefore be used to evaluate the efficacy of current and evolving therapeutic strategies, targeting myelination of the CNS.

Object From Motion (OFM) and Time-constrained stereo protocols are sensitive tools to identify monocular and binocular dynamic visual function deficits, which are uniquely affected in optic neuritis patients. Furthermore, these tests may be used as quantitative noninvasive tools to assess the extent of myelination along visual pathways.

动态视觉测试，以确定和量化视觉损伤与修复继脱髓鞘视神经炎患者

In order to follow optic neuritis patients and evaluate the effectiveness of their treatment, a handy, accurate and quantifiable tool is required to ...

Catheterization of the Carotid Artery and Jugular Vein to Perform Hemodynamic Measures, Infusions and Blood Sampling in a Conscious Rat Model

The success of a small animal model to study critical illness is, in part, dependent on the ability of the model to simulate the human condition. Intra-tracheal inoculation of a known amount of bacteria has been successfully used to reproduce the pathogenesis of pneumonia which then develops into sepsis. Monitoring hemodynamic parameters and providing standard clinical treatment including infusion of antibiotics, fluids and drugs to maintain blood pressure is critical to simulate routine supportive care in this model but to do so requires both arterial and venous vascular access. The video details the surgical technique for implanting carotid artery and common jugular vein catheters in an anesthetized rat. Following a 72 hr recovery period, the animals will be re-anesthetized and connected to a tether and swivel setup attached to the rodent housing which connects the implanted catheters to the hemodynamic monitoring system. This setup allows free movement of the rat during the study while continuously monitoring pressures, infusing fluids and drugs (antibiotics, vasopressors) and performing blood sampling.

Vascular accesses to measure hemodynamics, provide fluids and perform blood sampling are important to any small animal model study. We present a technique for implanting catheters into the carotid artery and the common jugular vein in an anesthetized rat for connecting to a system to perform monitoring, infusions and sampling.

颈动脉和颈静脉导管在有意识大鼠模型进行血流动力学措施，输液和血液采样

The success of a small animal model to study critical illness is, in part, dependent on the ability of the model to simulate the human condition. ...

Instillation and Fixation Methods Useful in Mouse Lung Cancer Research

The ability to instill live agents, cells, or chemicals directly into the lung without injuring or killing the mice is an important tool in lung cancer research. Although there are a number of methods that have been published showing how to intubate mice for pulmonary function measurements, none are without potential problems for rapid tracheal instillation in large cohorts of mice. In the present paper, a simple and quick method is described that enables an investigator to carry out such instillations in an efficient manner. The method does not require any special tools or lighting and can be learned with very little practice. It involves anesthetizing a mouse, making a small incision in the neck to visualize the trachea, and then inserting an intravenous catheter directly. The small incision is quickly closed with tissue adhesive, and the mice are allowed to recover. A skilled student or technician can do instillations at an average rate of 2 min/mouse. Once the cancer is established, there is frequently a need for quantitative histologic analysis of the lungs. Traditionally pathologists usually do not bother to standardize lung inflation during fixation, and analyses are often based on a scoring system that can be quite subjective. While this may sometime be sufficiently adequate for gross estimates of the size of a lung tumor, any proper stereological quantification of lung structure or cells requires a reproducible fixation procedure and subsequent lung volume measurement. Here we describe simple reliable procedures for both fixing the lungs under pressure and then accurately measuring the fixed lung volume. The only requirement is a laboratory balance that is accurate over a range of 1 mg&#8211;300 g. The procedures presented here thus could greatly improve the ability to create, treat, and analyze lung cancers in mice.

The goal of this paper is to describe simple methods that will greatly aid in the setup and analysis of mouse lungs with lung cancer or other pathologies. We present 3 protocols to simply and reliably carry out lung instillations, fixation, and lung volume measurements.

灌输和固定方法有用的小鼠肺癌研究

The ability to instill live agents, cells, or chemicals directly into the lung without injuring or killing the mice is an important tool in lung cancer ...

A Simple Mechanical Procedure to Create Limbal Stem Cell Deficiency in Mouse

Limbal stem cell deficiency (LSCD) is a state of malfunction or loss of limbal epithelial stem cells, after which the corneal epithelium is replaced with conjunctiva. Patients suffer from recurrent corneal defects, pain, inflammation, and loss of vision.
Previously, a murine model of LSCD was described and compared to two other models. The goal was to produce a consistent mouse model of LSCD that both mimics the phenotype in humans and lasts long enough to make it possible to study the disease pathophysiology and to evaluate new treatments. Here, the technique is described in more detail.
A motorized tool with a rotating burr has been designed to remove the rust rings from the corneal surface or to smooth the pterygium bed in patients. It is a suitable device to create the desired LSCD model. It is a readily available, easy-to-use tool with a fine tip that makes it appropriate for working on small eyes, as in mice. Its application prevents unnecessary trauma to the eye and it does not result in unwanted injuries, as often is the case with chemical injury models. As opposed to a blunt scraper, it removes the epithelium with the basement membrane. In this protocol, the limbal area was abraded two times, and then the whole corneal epithelium was shaved from limbus to limbus. To avoid stroma injury, care was taken not to brush the corneal surface once the epithelium was already removed.

The following article provides an easy, reproducible technique to effectively create a sustainable mouse model of limbal stem cell deficiency (LSCD). This animal model is useful in testing and comparing the efficacy of treatments for limbal stem cell diseases.

一个简单的机械过程来创建在小鼠角膜缘干细胞缺乏症

Limbal stem cell deficiency (LSCD) is a state of malfunction or loss of limbal epithelial stem cells, after which the corneal epithelium is replaced with ...

A Model to Simulate Clinically Relevant Hypoxia in Humans

In case of apnea, arterial partial pressure of oxygen (pO2) decreases, while partial pressure of carbon dioxide (pCO2) increases. To avoid damage to hypoxia sensitive organs such as the brain, compensatory circulatory mechanisms help to maintain an adequate oxygen supply. This is mainly achieved by increased cerebral blood flow. Intermittent hypoxia is a commonly seen phenomenon in patients with obstructive sleep apnea. Acute airway obstruction can also result in hypoxia and hypercapnia. Until now, no adequate model has been established to simulate these dynamics in humans. Previous investigations focusing on human hypoxia used inhaled hypoxic gas mixtures. However, the resulting hypoxia was combined with hyperventilation and is therefore more representative of high altitude environments than of apnea. Furthermore, the transferability of previously performed animal experiments to humans is limited and the pathophysiological background of apnea induced physiological changes is poorly understood. In this study, healthy human apneic divers were utilized to mimic clinically relevant hypoxia and hypercapnia during apnea. Additionally, pulse-oximetry and Near Infrared Spectroscopy (NIRS) were used to evaluate changes in cerebral and peripheral oxygen saturation before, during, and after apnea.

Hypoxia simulation in humans has usually been performed by inhaling hypoxic gas mixtures. For this study, apneic divers were used to simulate dynamic hypoxia in humans. Additionally, physiological changes in desaturation and re-saturation kinetics were evaluated with non-invasive tools such as Near-Infrared-Spectroscopy (NIRS) and peripheral oxygenation saturation (SpO2).

一个模型来模拟人类临床相关性缺氧

In case of apnea, arterial partial pressure of oxygen (pO2) decreases, while partial pressure of carbon dioxide (pCO2) increases. To avoid damage to ...

A Clinical Trial Assessing the Safety, Efficacy, and Delivery of Olive-Oil-Based Three-Chamber Bags for Parenteral Nutrition

Limited evidence exists to precisely estimate efficacy and safety differences between parenteral nutrition (PN) prepared using olive-oil-based three-chamber bags (3CBs) and soybean-oil-based compounded bags (CoBs) in hospitalized adult patients. We designed a multicenter, randomized, prospective, open-label, noninferiority protocol to compare the efficacy, safety, and distribution of olive-oil-based 3CBs and soybean-oil-based CoB formulations in adult Chinese patients requiring PN during surgical intervention. Subjects were randomized to receive either one of the study treatments using an interactive voice or web-based recognition system in accordance with the randomization code. Randomization was further stratified based on the study site and surgical category. Both treatment groups received similar amounts of calories and protein. In addition, the two study treatments contained a similar composition of the amino-acid component. The only difference between the two PN formulations was the lipid constitution. The duration of administration of study treatments was a minimum of 5 days up to a maximum of 14 days after the surgical procedure. The primary efficacy endpoint was serum prealbumin levels on day 5 of the study. Noninferiority was proved if the anti-log of the lower bound of the 95% confidence interval (CI) of the treatment difference was at least 0.80. Other efficacy measures included treatment preparation time; duration to achieve tolerability of oral nutrition; associated infectious complications; length of hospitalization; and laboratory assessment of markers of nutrition, inflammation, metabolism, and oxidative stress. A total of 458 patients were enrolled in the study. The results showed that olive-oil-based 3CBs were non-inferior to soybean-based CoBs, besides being well tolerated. The infection rate was found to be significantly lower in the olive-oil-based 3CB group. Thus, this study may be used as a reference for future research on lipid emulsion and 3CBs.

Here, we present a protocol for a study comparing the efficacy, safety, and delivery of olive-oil-based 3CB and soybean-oil-based CoB formulations in adults requiring parenteral nutrition. The results revealed that olive-oil-based 3CBs is non-inferior and well tolerated compared to soybean formulations.

一项临床试验，评估基于橄榄油的三腔袋的亲子营养的安全性、有效性和交付

Limited evidence exists to precisely estimate efficacy and safety differences between parenteral nutrition (PN) prepared using olive-oil-based ...

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Longitudinal evaluations of critically ill patients by combinations of clinical examination, biochemical analysis and critical care ultrasonography (CCUS) may detect adverse events of interventions such as fluid overload at an early stage. The Simple Intensive Care Studies (SICS) is a research line that focuses on the prognostic and diagnostic value of combinations of clinical variables.
The SICS-I specifically focused on the use of clinical variables obtained within 24 h of acute admission for prediction of cardiac output (CO) and mortality. Its sequel, SICS-II, focuses on repeated evaluations during ICU admission. The first clinical examination by trained researchers is performed within 3 h after admission consisting of physical examination and educated guessing. The second clinical examination is performed within 24 h after admission and includes physical examination and educated guessing, biochemical analysis and CCUS assessments of heart, lungs, inferior vena cava (IVC) and kidney. This evaluation is repeated at days 3 and 5 after admission. CCUS images are validated by an independent expert, and all data is registered in an online secured database. Follow-up at 90 days includes registration of complications and survival status according to patient&#39;s medical charts and the municipal person registry. The primary focus of SICS-II is the association between venous congestion and organ dysfunction.
The purpose of publishing this protocol is to provide details on the structure and methods of this on-going prospective observational cohort study allowing answering multiple research questions. The design of the data collection of combined clinical examination and CCUS assessments in critically ill patients are explicated. The SICS-II is open for other centers to participate and is open for other research questions that can be answered with our data.

<meta charset="utf8"></head><body>简单重症监护研究中重复临床检查和重症监护超声检查的观察性研究方案

Structured protocols are necessary to provide answers on research questions in critically ill patients. The Simple Intensive Care Studies (SICS) provides an infrastructure for repeated measurements in critically ill patients including clinical examination, biochemical analysis and ultrasonography. SICS projects have specific focus but the structure is flexible to other investigations.

简单重症监护研究中重复临床检查和重症监护超声检查的观察性研究方案

Longitudinal evaluations of critically ill patients by combinations of clinical examination, biochemical analysis and critical care ultrasonography (CCUS) ...

Clinical Practice Protocol of Creative Music Therapy for Preterm Infants and Their Parents in the Neonatal Intensive Care Unit

Creative music therapy for preterm infants and their parents (CMT) has emerged as a promising family-integrated early intervention involving communicative musicality to improve infant development, parental well-being, and bonding. It aims at relaxing and nurturing the infant as well as promoting safety and social interaction for the parent-infant dyad. A music therapist specially trained in CMT hums or sings in an infant-directed, improvised, lullaby style continually adjusting to the individual needs, expressions, and breathing pattern of the preterm infant. Based on the principles of family-integrated care, the family is incorporated individually in the therapeutic process, namely by delivering CMT during kangaroo care (KC) and by motivating and facilitating parental vocal interaction with their infant to strengthen the parent-infant bonding. CMT aims at relaxing, stimulating, and coregulating premature infants at a time when many other interventions are still risky and can overwhelm the vulnerable patient group. CMT may be advantageous not by educating and teaching parents, but rather by uncovering the intuitive capacities of parenting that are often overshadowed by the traumatic experience of preterm birth. However, CMT can only be provided when the infants are clinically stable. CMT with parental integration is feasible when parents are available and receptive to participate. This paper presents a detailed protocol on how to use CMT to empower preterm infants and their families.

Creative music therapy for preterm infants and their parents has emerged as a promising family-integrated early intervention. We present a detailed protocol on how to use vocal interaction, humming, or singing to empower preterm infants and their families.

新生儿重症监护病房早产儿及其家长创造性音乐治疗的临床实践规程

Creative music therapy for preterm infants and their parents (CMT) has emerged as a promising family-integrated early intervention involving communicative ...

利用视觉和叙事方法，以实现公平的进程中，在临床护理

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一个模型来模拟人类临床相关性缺氧

一项临床试验，评估基于橄榄油的三腔袋的亲子营养的安全性、有效性和交付

简单重症监护研究中重复临床检查和重症监护超声检查的观察性研究方案

简单重症监护研究中重复临床检查和重症监护超声检查的观察性研究方案

新生儿重症监护病房早产儿及其家长创造性音乐治疗的临床实践规程