李金娜
【摘要】 目的:探討積極心理干預(yù)聯(lián)合有氧運(yùn)動(dòng)對(duì)胃癌患者自我感受負(fù)擔(dān)及社會(huì)適應(yīng)能力的影響。方法:選取2018年1月-2020年12月遼陽(yáng)市中心醫(yī)院腫瘤科收治的330例胃癌患者,按照隨機(jī)數(shù)字表法將患者分成干預(yù)組和對(duì)照組,各165例。對(duì)照組給予常規(guī)護(hù)理模式,干預(yù)組在對(duì)照組的基礎(chǔ)上輔以積極心理干預(yù)聯(lián)合有氧運(yùn)動(dòng)。評(píng)估和對(duì)比兩組患者癌因性疲乏、希望水平、自我感受負(fù)擔(dān)、生活質(zhì)量及社會(huì)適應(yīng)能力。結(jié)果:干預(yù)后,兩組患者行為、情感、軀體和認(rèn)知等癌因性疲乏維度評(píng)分均明顯降低,且干預(yù)組行為、情感、軀體和認(rèn)知等癌因性疲乏維度評(píng)分均明顯低于對(duì)照組(P<0.05);兩組患者采取的積極行動(dòng)、對(duì)現(xiàn)實(shí)與未來(lái)的積極態(tài)度和與他人保持親密關(guān)系等希望水平維度評(píng)分均明顯提高,且干預(yù)組患者采取的積極行動(dòng)、對(duì)現(xiàn)實(shí)與未來(lái)的積極態(tài)度和與他人保持親密關(guān)系等希望水平維度評(píng)分均明顯高于對(duì)照組(P<0.05);兩組患者生活質(zhì)量各維度評(píng)分均明顯提高,且干預(yù)組患者生活質(zhì)量各維度評(píng)分均明顯高于對(duì)照組(P<0.05);兩組患者經(jīng)濟(jì)、身體和情感等自我感受負(fù)擔(dān)維度評(píng)分均明顯降低,且干預(yù)組患者經(jīng)濟(jì)、身體和情感等自我感受負(fù)擔(dān)維度評(píng)分均明顯低于對(duì)照組(P<0.05);兩組患者焦慮和抑郁、自尊和自我接納、態(tài)度、歸屬感、自我控制和自我效能等社會(huì)適應(yīng)能力維度評(píng)分均明顯提高,且干預(yù)組患者社會(huì)適應(yīng)能力維度評(píng)分均明顯高于對(duì)照組(P<0.05)。結(jié)論:積極心理干預(yù)聯(lián)合有氧運(yùn)動(dòng)應(yīng)用于胃癌患者,可有效降低癌因性疲乏,提高希望水平,改善生活質(zhì)量,降低自我感受負(fù)擔(dān),增強(qiáng)社會(huì)適應(yīng)能力,值得臨床進(jìn)一步研究并推廣。
【關(guān)鍵詞】 積極心理干預(yù) 有氧運(yùn)動(dòng) 胃癌 自我感受負(fù)擔(dān) 社會(huì)適應(yīng)能力
[Abstract] Objective: To explore the effects of positive psychological intervention combined with aerobic exercise on self-perceived burden and social adaptability in patients with gastric cancer. Method: A total of 330 patients with gastric cancer treated in the oncology department of Liaoyang Central Hospital from January 2018 to December 2020 were divided into intervention group (n=165) and control group (n=165) according to the random number table method. The control group was given routine nursing mode, and the intervention group was supplemented with positive psychological intervention combined with aerobic exercise on the basis of the control group. Cancer-related fatigue, hope level, self-perceived burden, quality of life and social adaptation were evaluated and compared between the two groups. Result: After intervention, the dimensions of cancer-related fatigue scores such as behavior, emotion, body and cognition in the two groups decreased significantly, and the dimensions of cancer-related fatigue scores such as behavior, emotion, body and cognition in the intervention group were significantly lower than those in the control group (P<0.05); the dimensions of of hope levels scores such as positive action, positive attitude towards reality and future and maintaining close relationship with others in the two groups were significantly improved, and those of the intervention group were significantly higher than those of the control group (P<0.05); the scores of all dimensions of quality of life in the two groups were significantly improved, and the scores of quality of life in the intervention group were significantly higher than those in the control group (P<0.05); the dimensions of economic, physical and emotional self-feeling burden scores in the two groups were significantly reduced, and the dimensions of economic, physical and emotional self-feeling burden scores in the intervention group were significantly lower than those in the control group (P<0.05); the dimensions of social adaptability scores such as anxiety and depression, self-esteem and self-acceptance, attitude, sense of belonging, self-control and self-efficacy were significantly improved in the two groups, and the dimensions of social adaptability scores in the intervention group were significantly higher than those in the control group (P<0.05). Conclusion: The application of positive psychological intervention combined with aerobic exercise in patients with gastric cancer can effectively reduce cancer fatigue, improve the hope level and the quality of life, reduce the burden of self-perception, and enhance social adaptability, which is worthy of further clinical research and promotion.
[Key words] Positive psychological intervention Aerobic exercise Gastric cancer Self-perceived burden Social adaptability
First-author’s address: Liaoyang Central Hospital, Liaoning Province, Liaoyang 111000, China
doi:10.3969/j.issn.1674-4985.2022.03.022
胃癌是指起源于胃黏膜細(xì)胞的消化道惡性腫瘤,隨著經(jīng)濟(jì)的發(fā)展和生命科學(xué)的進(jìn)步,其在中國(guó)的檢出率和死亡率遠(yuǎn)高于世界平均水平,且呈現(xiàn)年輕化趨勢(shì)[1-2]。根治術(shù)和術(shù)后放化療是臨床控制胃癌病情的常見(jiàn)方式,研究發(fā)現(xiàn),早期胃癌根治術(shù)后5年生存率高達(dá)90%[3],而中晚期通過(guò)有效的根治術(shù)、藥物化療可明顯延長(zhǎng)生存期。但胃癌患者普遍存在癌性疲乏,其體力和精力出現(xiàn)明顯降低等特征,同時(shí)伴有冷漠、沮喪、情緒低落等負(fù)面情緒,嚴(yán)重降低治療依從性,加重患者經(jīng)濟(jì)、情感和身體等方面自我感受負(fù)擔(dān)[4]。研究表明,心理因素和社會(huì)適應(yīng)能力是癌癥患者治療和康復(fù)的重要因素[5],積極心理學(xué)是新興學(xué)科,其旨在倡導(dǎo)人們幸福、快樂(lè)和希望感等積極取向,已有臨床醫(yī)護(hù)工作者將其應(yīng)用于癌癥患者,但臨床效果欠佳。有氧運(yùn)動(dòng)是常見(jiàn)的理療方式,可通過(guò)針對(duì)性有氧運(yùn)動(dòng)方案增強(qiáng)患者新陳代謝功能,緩解焦慮、抑郁情緒[6],二者聯(lián)合應(yīng)用于胃癌患者的護(hù)理方式相關(guān)研究較少,本研究探討積極心理干預(yù)聯(lián)合有氧運(yùn)動(dòng)對(duì)胃癌患者自我感受負(fù)擔(dān)及社會(huì)適應(yīng)能力的影響,旨在為臨床提供依據(jù)。現(xiàn)報(bào)道如下。
1 資料與方法
1.1 一般資料 選取2018年1月-2020年12月遼陽(yáng)市中心醫(yī)院腫瘤科收治的330例胃癌患者,按照隨機(jī)數(shù)字表法將其分成干預(yù)組和對(duì)照組,各165例。納入標(biāo)準(zhǔn):(1)均經(jīng)影像學(xué)、病理組織學(xué)等確診為胃癌,并符合胃癌診斷標(biāo)準(zhǔn)[7];(2)學(xué)歷小學(xué)以上,智力和溝通水平正常,具有一定的閱讀和理解能力,可獨(dú)立填寫量表;(3)TNM分期為Ⅰ~Ⅲ期,預(yù)計(jì)生存期為6個(gè)月以上;(4)年齡18~65歲;(5)患者及家屬知情同意本研究。排除標(biāo)準(zhǔn):(1)合并其他惡性腫瘤、凝血功能障礙或自身免疫疾病者;(2)存在精神病史或長(zhǎng)期服用抗抑郁藥物者;(3)既往行積極心理干預(yù)等護(hù)理模式;(4)入院后無(wú)法存活6個(gè)月;(5)不配合者。本研究經(jīng)本院醫(yī)學(xué)倫理委員會(huì)批準(zhǔn),患者對(duì)本研究知情,并簽署知情同意書。
1.2 方法 (1)對(duì)照組患者給予常規(guī)的術(shù)后護(hù)理,通過(guò)宣傳手冊(cè)、知識(shí)講座及定期答疑等方式對(duì)患者及其家屬進(jìn)行知識(shí)宣教,內(nèi)容涉及胃癌術(shù)后治療措施、用藥指導(dǎo)、營(yíng)養(yǎng)支持及康復(fù)運(yùn)動(dòng)等,確?;颊呒捌浼覍賹?duì)疾病護(hù)理相關(guān)知識(shí)熟練掌握。若患者出現(xiàn)負(fù)面情緒而影響治療積極性,則需行相應(yīng)心理干預(yù)。(2)干預(yù)組患者在對(duì)照組的基礎(chǔ)上輔以積極心理干預(yù)和有氧運(yùn)動(dòng),首先科室成立護(hù)理干預(yù)小組,小組成員涉及1名副主任醫(yī)師和6名高年資護(hù)理人員,均能夠熟練掌握應(yīng)急事件、護(hù)理知識(shí)和技能及胃癌護(hù)理知識(shí)等護(hù)理干預(yù)技巧。所有成員均經(jīng)過(guò)積極心理系統(tǒng)培訓(xùn),涵蓋積極心理學(xué)定義、起源、干預(yù)措施等內(nèi)容,并考核通過(guò)。積極心理干預(yù)從三個(gè)方面實(shí)施,即一對(duì)一訪談和情緒疏導(dǎo)、患者交流會(huì)及每日記錄美好事件等。①一對(duì)一訪談和情緒疏導(dǎo):住院期間與患者進(jìn)行5次一對(duì)一訪談,主動(dòng)與患者及其家屬溝通,增強(qiáng)其對(duì)疾病的認(rèn)知程度,若患者出現(xiàn)“癌癥預(yù)后肯定差”“癌癥治療費(fèi)用高”及“過(guò)分夸大病情”等言論和思想時(shí),可通過(guò)既往病例和權(quán)威知識(shí)說(shuō)服胃癌患者及其家屬,告知患者胃癌的流行病學(xué)數(shù)據(jù),并結(jié)合患者實(shí)際情況,使患者正確認(rèn)知胃癌相關(guān)知識(shí),同時(shí)分析其焦慮、恐懼等負(fù)面情緒,引導(dǎo)其向積極態(tài)度轉(zhuǎn)向,積極遵循醫(yī)囑,詳細(xì)介紹化療、放療的必要性和重要性,以延長(zhǎng)生存期。②引導(dǎo)并建立胃癌患者交流會(huì),以尋求社會(huì)、家庭的幫助,在交流會(huì)上,鼓勵(lì)患者分享與病魔斗爭(zhēng)的心得和案例,加強(qiáng)患者治療疾病的信心和決心,同時(shí)鼓勵(lì)患者說(shuō)出自己的擔(dān)憂和負(fù)面情緒,發(fā)揮團(tuán)體優(yōu)勢(shì),應(yīng)用感同身受的思維從根源舒緩負(fù)面情緒。③每日記錄美好事件:鼓勵(lì)患者記錄一天內(nèi)發(fā)生的美好事件,以日記形式,書寫或記錄在手機(jī)便簽內(nèi),引導(dǎo)患者體會(huì)生活的美好之處,增強(qiáng)其幸福感。護(hù)理小組制訂科學(xué)的有氧運(yùn)動(dòng)方案,每周訓(xùn)練3次,分別為周一、周三和周五下午三點(diǎn),康復(fù)時(shí)間為20~25 min,運(yùn)動(dòng)前進(jìn)行準(zhǔn)備活動(dòng),舒展筋骨,拉伸關(guān)節(jié),防止受傷。開(kāi)展常規(guī)有氧運(yùn)動(dòng),依次為頭部旋轉(zhuǎn)、上提單肩、上提雙肩、向前拉臂、上舉側(cè)屈、左右旋體、上舉前屈、多角度擺髖、跳踏、跑步、原地?cái)[臂等,重復(fù)2~3次,最后進(jìn)行上肢擺動(dòng)和原地踏步等運(yùn)動(dòng),持續(xù)4周。
1.3 觀察指標(biāo)及評(píng)價(jià)標(biāo)準(zhǔn)
1.3.1 癌因性疲乏 于干預(yù)前后應(yīng)用Piper疲乏量表評(píng)估兩組患者癌因性疲乏,該量表包括情感、軀體、認(rèn)知和行為4個(gè)維度,共22個(gè)條目,每個(gè)條目0~10分,分值越高表示患者疲乏程度越嚴(yán)重,該量表Cronbach’s α系數(shù)為0.854,信效度較高[8]。
1.3.2 希望水平 于干預(yù)前后應(yīng)用Herth希望量表評(píng)估兩組患者希望水平,該量表包括采取的積極行動(dòng)、對(duì)現(xiàn)實(shí)與未來(lái)的積極態(tài)度和與他人保持親密關(guān)系3個(gè)維度,12個(gè)條目,總分為48分,分值越高表示患者希望水平越高,該量表Cronbach’s α系數(shù)為0.870,信效度較高[9]。
1.3.3 生活質(zhì)量 于干預(yù)前后應(yīng)用健康調(diào)查簡(jiǎn)表(SF-36)評(píng)估兩組患者生活質(zhì)量,該量表共包括生理功能、生理職能、軀體疼痛、總體健康、活力、社會(huì)功能、情感職能和精神健康8個(gè)維度,共36個(gè)問(wèn)題,每個(gè)維度滿分為100分,分值越高提示患者健康情況越好,該量表Cronbach’s α系數(shù)為0.721,信效度較高[10]。
1.3.4 自我感受負(fù)擔(dān) 于干預(yù)前后應(yīng)用自我感受負(fù)擔(dān)量表評(píng)估兩組患者自我感受負(fù)擔(dān),該量表包括經(jīng)濟(jì)負(fù)擔(dān)、身體負(fù)擔(dān)及情感負(fù)擔(dān)3個(gè)維度,共10個(gè)條目,每個(gè)條目應(yīng)用5級(jí)評(píng)分法,除第8個(gè)條目為負(fù)向計(jì)分,其余均為正向計(jì)分,分值越高表示患者負(fù)擔(dān)感受越嚴(yán)重,該量表Cronbach’s α系數(shù)為0.910,信效度較高[11]。
1.3.5 社會(huì)適應(yīng)能力 于干預(yù)前后應(yīng)用心理社會(huì)適應(yīng)能力量表評(píng)估兩組患者社會(huì)適應(yīng)能力,該量表包括自尊和自我接納、焦慮和抑郁、歸屬感、自我控制、自我效能及態(tài)度6個(gè)維度,共77個(gè)條目,條目計(jì)分方式為4級(jí)評(píng)分法,分值越高表示患者心理社會(huì)適應(yīng)能力越強(qiáng),該量表Cronbach’s α系數(shù)為0.782,信效度較高[12]。
1.4 統(tǒng)計(jì)學(xué)處理 采用SPSS 25.0統(tǒng)計(jì)學(xué)軟件處理數(shù)據(jù),計(jì)數(shù)資料以率(%)表示,比較采用字2檢驗(yàn);計(jì)量資料以(x±s)表示,組內(nèi)比較采用配對(duì)t檢驗(yàn),組間比較采用獨(dú)立樣本t檢驗(yàn)。P<0.05提示差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 兩組患者一般資料比較 兩組患者性別、年齡、體重指數(shù)、文化程度、TNM分期和治療方法比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性,見(jiàn)表1。
2.2 兩組患者癌因性疲乏比較 兩組患者干預(yù)前行為、情感、軀體和認(rèn)知等癌因性疲乏維度評(píng)分比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);干預(yù)后,兩組患者行為、情感、軀體和認(rèn)知等癌因性疲乏維度評(píng)分均明顯降低,且干預(yù)組行為、情感、軀體和認(rèn)知等癌因性疲乏維度評(píng)分均明顯低于對(duì)照組(P<0.05)。見(jiàn)表2。
2.3 兩組患者希望水平比較 兩組患者干預(yù)前采取的積極行動(dòng)、對(duì)現(xiàn)實(shí)與未來(lái)的積極態(tài)度和與他人保持親密關(guān)系等希望水平維度評(píng)分比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);干預(yù)后,兩組患者采取的積極行動(dòng)、對(duì)現(xiàn)實(shí)與未來(lái)的積極態(tài)度和與他人保持親密關(guān)系等希望水平維度評(píng)分均明顯提高,且干預(yù)組患者采取的積極行動(dòng)、對(duì)現(xiàn)實(shí)與未來(lái)的積極態(tài)度和與他人保持親密關(guān)系等希望水平維度評(píng)分均明顯高于對(duì)照組(P<0.05)。見(jiàn)表3。
2.4 兩組患者生活質(zhì)量比較 兩組患者干預(yù)前生活質(zhì)量各維度評(píng)分比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);干預(yù)后,兩組患者生活質(zhì)量各維度評(píng)分均明顯提高,且干預(yù)組患者生活質(zhì)量各維度評(píng)分均明顯高于對(duì)照組(P<0.05)。見(jiàn)表4。
2.5 兩組患者自我感受負(fù)擔(dān)比較 兩組患者干預(yù)前經(jīng)濟(jì)、身體和情感等自我感受負(fù)擔(dān)維度評(píng)分比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);干預(yù)后,兩組患者經(jīng)濟(jì)、身體和情感等自我感受負(fù)擔(dān)維度評(píng)分均明顯降低,且干預(yù)組患者經(jīng)濟(jì)、身體和情感等自我感受負(fù)擔(dān)維度評(píng)分均明顯低于對(duì)照組(P<0.05)。見(jiàn)表5。
2.6 兩組患者社會(huì)適應(yīng)能力比較 兩組患者干預(yù)前焦慮和抑郁、自尊和自我接納、態(tài)度、歸屬感、自我控制和自我效能等社會(huì)適應(yīng)能力維度評(píng)分比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);干預(yù)后,兩組患者焦慮和抑郁、自尊和自我接納、態(tài)度、歸屬感、自我控制和自我效能等社會(huì)適應(yīng)能力維度評(píng)分均明顯提高,且干預(yù)組患者社會(huì)適應(yīng)能力維度評(píng)分均明顯高于對(duì)照組(P<0.05)。見(jiàn)表6。
3 討論
胃癌多發(fā)于40~70歲人群,早期臨床癥狀較為隱匿,僅為上腹不適、噯氣及惡心嘔吐等,而中晚期以疼痛和體重減輕為主要癥狀,其病因與飲食、幽門螺桿菌感染及遺傳相關(guān)[13]。研究發(fā)現(xiàn),通過(guò)合理治療和定期復(fù)查可有效控制癌細(xì)胞擴(kuò)散,延長(zhǎng)生存期[14],但患者存在的自我負(fù)擔(dān)感和社會(huì)適應(yīng)能力制約胃癌治療的配合度和臨床療效,因而尋找積極護(hù)理模式,以消除患者負(fù)面情緒,對(duì)提高治療依從性等具有重要臨床意義。常規(guī)胃癌術(shù)后護(hù)理較為單調(diào),僅為健康宣教、治療方案介紹及術(shù)后康復(fù)訓(xùn)練等,針對(duì)治療積極性的患者行相應(yīng)的心理干預(yù),但該方式護(hù)理針對(duì)性較弱,無(wú)法達(dá)到理想護(hù)理效果[15]。與消極心理學(xué)相比,積極心理學(xué)主要研究集中在樂(lè)觀態(tài)度看待人性、挖掘面對(duì)困難的潛力及幸福感情緒體驗(yàn)等方面[16];而規(guī)律有氧運(yùn)動(dòng)可分泌內(nèi)啡肽和5-羥色胺等化學(xué)物質(zhì),發(fā)揮緩解疲勞、恢復(fù)體能等生理作用[17]。
干預(yù)后,兩組患者癌因性疲乏諸維度評(píng)分明顯降低,且干預(yù)組癌因性疲乏諸維度評(píng)分明顯低于對(duì)照組(P<0.05);兩組患者希望水平諸維度評(píng)分明顯提高,且干預(yù)組患者希望水平諸維度評(píng)分明顯高于對(duì)照組(P<0.05);兩組患者生活質(zhì)量各維度評(píng)分明顯提高,且干預(yù)組患者生活質(zhì)量各維度評(píng)分明顯高于對(duì)照組(P<0.05),提示積極心理干預(yù)聯(lián)合有氧運(yùn)動(dòng)可明顯降低癌因性疲乏,提高希望水平,改善生活質(zhì)量。相關(guān)研究表明,癌癥患者均存在不同程度的恐懼、焦慮及悲觀等負(fù)性情緒,且因疾病知識(shí)的局限性,極易出現(xiàn)癌因疲乏性,喪失治療和生活的希望。積極心理學(xué)強(qiáng)調(diào)喚醒患者對(duì)生活的積極態(tài)度、體驗(yàn)和情緒,可通過(guò)分享案例、記錄美好事情和針對(duì)性訪談等途徑建立胃癌患者心理平衡狀態(tài),提高治療積極性,增強(qiáng)其主觀幸福感。而有氧運(yùn)動(dòng)不僅可促進(jìn)術(shù)后恢復(fù)、緩解放化療的毒副反應(yīng),而且還可以促進(jìn)血液循環(huán),修復(fù)受損免疫系統(tǒng),改善生活質(zhì)量。
采用不同模式護(hù)理干預(yù)后,兩組患者經(jīng)濟(jì)、身體和情感等自我感受負(fù)擔(dān)諸維度評(píng)分明顯降低,且干預(yù)組患者經(jīng)濟(jì)、身體和情感等自我感受負(fù)擔(dān)諸維度評(píng)分明顯低于對(duì)照組(P<0.05);兩組患者焦慮和抑郁、自尊和自我接納、態(tài)度、歸屬感、自我控制和自我效能等社會(huì)適應(yīng)能力諸維度評(píng)分明顯提高,且干預(yù)組患者社會(huì)適應(yīng)能力諸維度評(píng)分明顯高于對(duì)照組(P<0.05),提示積極心理干預(yù)聯(lián)合有氧運(yùn)動(dòng)可降低自我感受負(fù)擔(dān),增強(qiáng)社會(huì)適應(yīng)能力。分析認(rèn)為,社會(huì)適應(yīng)能力和自我感受負(fù)擔(dān)是評(píng)估癌癥患者臨床有效性的重要指標(biāo),積極心理干預(yù)通過(guò)組織病友交流會(huì),鼓勵(lì)患者積極參與分享臨床癥狀和治療過(guò)程中遇到的問(wèn)題等,建立共情的病友關(guān)系,堅(jiān)定與癌癥抗?fàn)幍降椎臎Q心和信心,提高其社會(huì)適應(yīng)能力。同時(shí),充分與患者家屬溝通,根據(jù)患者實(shí)際病情選擇最佳且符合經(jīng)濟(jì)能力的治療方案,希望家屬?gòu)男袆?dòng)、情感和經(jīng)濟(jì)方面全方面支持患者治療,降低其自我感受負(fù)擔(dān)。有氧運(yùn)動(dòng)可增強(qiáng)患者心肺耐力,恢復(fù)免疫功能,同時(shí)其還可以分泌多巴胺愉悅患者心情,更加積極融入病友群體和社會(huì)。
綜上所述,積極心理干預(yù)聯(lián)合有氧運(yùn)動(dòng)應(yīng)用于胃癌患者,可有效降低癌因性疲乏,提高希望水平,改善生活質(zhì)量,降低自我感受負(fù)擔(dān),增強(qiáng)社會(huì)適應(yīng)能力,值得臨床進(jìn)一步研究并推廣。
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(收稿日期:2021-03-31) (本文編輯:占匯娟)