骨关节炎诊治指南的临床转化应用

近些年,针对骨关节炎(osteoarthritis,OA)的诊断与治疗,出现过多种多样的指南,但是不同的指南由于纳入证据等级的不同,导致其推荐强度不同,而且指南过于文本化,一定程度上限制了其在临床的转化应用。2016年国际骨关节炎会议(OARSI)通过更新现有指南,以求得到OA治疗的临床实践指导方针,并针对手部OA、髋关节OA、膝关节OA提出了4种用户友好型的治疗路径,最终的目的是促进指南的临床转化。     

《欧洲血管外科学会（ESVS）2021年静脉血栓管理临床实践指南》临床热点解读

欧洲血管外科学会（ESVS）于2021年在《European Journal of Vascular and Endovascular Surgery》发表了该协会首个静脉血栓诊疗领域的指南：《欧洲血管外科学会（ESVS）2021年静脉血栓管理临床实践指南》,该指南包括了下肢深静脉血栓形成（DVT）、上肢DVT、浅静脉血栓形成（SVT）以及特殊部位血栓形成等方面,共给予了72条推荐意见;同时,除了关于治疗方法的推荐,还包括了健康经济学以及特殊患者人群的相关问题。该指南中的建议是通过对目前可以得到的研究证据进行分析及评估制定的,会对临床实践有较大的借鉴意义,但是,随着技术、证据以及知识的发展,指南可能需要不断更新。笔者团队根据指南更新的循证医学证据,结合临床中的热点问题,对指南给出的推荐意见做重点解读,以期更好地理解指南原则及实用建议。     

从2009年版NCCN指南的更新看肾癌诊治进展

美国国家综合癌症网络（National Comprehensive Cancer Network,NCCN）制订的《肿瘤学临床实践指南》是由美国专家团队根据各种肿瘤临床诊断和治疗研究的最新进展共同制定,并适时进行更新,为临床决策提供重要参考依据,成为全球肿瘤临床实践中应用最为广泛的指南。     

骨关节外科相关感染国外指南述评

近年来骨关节感染的临床实践在不断更新,但由于骨关节感染治疗失败率及复发率高,使得临床医生仍然对治疗策略感到困惑[1]。本文结合国内外最新指南,对骨关节相关感染的诊治作一述评。不同国家都先后制定了骨关节感染诊治指南,基本原则大同小异,但不同的指南侧重点各有不同。其中2014年韩国化疗协会、韩国感染病协会及韩国骨科医师协会联合出台了关于骨髓炎和化脓性骨关节炎的诊治流程,尤其对抗感染经验性治疗和选择性治疗中抗生素的选择作了详细的阐     

胃食管反流病的全病程管理策略：一项基于临床实践指南的证据图研究

胃食管反流病(GERD)是最常见的消化系统疾病之一, 其发病率高、临床症状表现复杂、难以进行标准治疗、医疗负担重。目前不同国家和学术组织发表了GERD的相关指南, 在指导临床实践的同时, 也存在部分推荐意见不一致的情况, 给当前GERD的临床全病程管理造成一定的困扰。本文总结GERD指南中的相关证据并制定其全病程管理策略, 为临床实践提供科学依据。首先, 检索专业指南网站、相关学会网站以及电子数据库, 纳入2010年以后发表或更新的GERD指南, 从症状、流行病学、诊断以及治疗等方面提取并整合推荐意见, 最终以证据图的形式呈现其管理流程。本文纳入24篇指南, 其中中文3篇, 英文21篇, 从GERD临床症状表现、诊断方法、内科治疗、抗反流手术及内镜治疗、心理支持治疗、中医治疗等多方面进行了证据汇总, 概括并图示了其临床实践管理流程。     

膝骨关节炎非手术治疗患者运动干预的最佳证据总结

目的 总结膝骨关节炎非手术治疗患者运动干预的最佳证据,为临床膝骨关节炎非手术治疗患者的运动康复提供参考。方法 确定循证问题,依照“6S”证据模型,计算机检索JBI循证卫生保健中心数据库、BMJ、英国国家卫生与临床优化研究所指南网等国内外数据库中关于膝骨关节炎非手术治疗患者运动干预的所有证据,包括指南、系统评价、证据总结、专家共识、临床决策、随机对照试验,检索时限为2018年2月10日至2023年2月10日。由2名研究者独立完成文献质量评价、证据提取和总结。结果 共纳入12篇文献,其中指南6篇,系统评价2篇,专家共识2篇以及随机对照试验2篇。从运动原则、运动评估、运动类型、运动强度、运动频率和时间、运动监测6个方面共汇总27条最佳证据。结论 膝骨关节炎患者运动方案的制定应遵循运动频率、强度、时间和类型原则,医护人员在临床应结合患者自身状况意愿、证据应用情境等因素选择证据,个体化制定患者的运动干预计划。     

NGC收录护理临床实践指南方法学分析

目的分析美国国立指南文库(National Guideline Clearinghouse,NGC)收录的护理临床实践指南现状,以期对我国护理临床实践指南的开发和应用提供借鉴。方法检索NGC网站获取护理临床实践指南,并提取护理临床实践指南基本信息和方法学内容,并将数据输入Excel,使用STATA12.0软件进行数据统计分析。结果共收录268部指南,均含有护理相关内容。发布机构最多的是医学协会或学会、主要针对用户为护士和执业医师、260部(97.01%)基于系统评价、246部(91.79%)采用评级指标进行证据的质量和推荐强度的评估、264部(98.51%)采用专家共识的方法给予指南制定建议。结论 NGC收录的护理临床实践指南在证据选择/收集、证据质量和推荐强度的评估以及制定建议的方法学方面仍需进一步完善。     

间歇导尿相关临床实践指南的质量评价及证据整合

目的评价间歇导尿相关临床实践指南的质量,整合现有指南的推荐意见,为规范间歇导尿临床实践提供循证依据。方法检索2009年1月至2019年3月国内外公开发表的间歇导尿相关临床实践指南,使用AGREEⅡ工具对纳入指南进行质量评价。结果共纳入7部指南,总体质量评价为A级3部,B级3部,C级1部,经证据整合,形成间歇导尿评估、实践、教育和管理4个方面共27条推荐意见。结论现有间歇导尿指南整体质量尚可,指南制定方法学和报告规范有待提高;所整合证据有较强的临床指导意义,可进行实践转化。     

益气养血方治疗骨关节炎机理窥探

骨关节炎是以关节慢性疼痛、僵硬、压痛、骨擦音及功能受限等为主要症状的退行性疾病.益气养血方在治疗气血两虚证骨关节炎中取得良好临床疗效,因此从立方依据、治疗优势及药理研究等方面进行理论分析探讨,认为益气养血方治疗骨关节炎理论完备,且有独特优势,作用机制可能与调控基质金属蛋白酶、细胞因子等相关.期望为临床论治骨关节炎提供更...     

独活寄生汤通过miRNAs调控炎症性骨关节炎软骨细胞功能改变的机制探讨

软骨细胞功能改变在骨关节炎病理过程中发挥重要的调控作用。炎症因子是介导骨关节炎软骨退变的主要因素,其表达与Micro RNAs(mi RNAs)密切相关。mi RNAs是一类在转录后水平调控基因表达的非编码蛋白的RNA分子,参与了软骨细胞增殖、分化,以及合成与分解代谢等生物学过程。中医药治疗骨关节炎独具特色,能够靶向调节mi RNAs介导的炎症反应,独活寄生汤长期运用于临床,能有效抑制关节炎症,其药效机制可能是通过调节骨关节炎软骨细胞中mi RNAs的表达,以及改变mi RNAs和炎症因子之间的相互协调作用而发挥对炎症性骨关节炎的治疗作用。多层次、多角度地探讨独活寄生汤的作用机制及药效物质基础,可为阐明独活寄生汤治疗炎症性骨关节炎提供新的研究思路。     

《中国髌股关节骨关节炎诊疗指南(2020年版)》要点解读

髌股关节骨关节炎(patellofemoral osteoarthritis,PFOA)是膝关节骨关节炎的一种重要亚型,因人群患病率高、疾病负担重,近年来受到广泛关注。为此,国家老年疾病临床医学研究中心(湘雅医院)、中华医学会骨科学分会关节外科学组以及《中华骨科杂志》编辑部组织并成立了指南制订专家小组,按照指南制订规范,于2020年9月发布了《中国髌股关节骨关节炎诊疗指南(2020年版)》,对我国PFOA临床诊疗实践的规范化具有重要指导意义。指南内容主要包括PFOA的诊断(症状、体征和影像学改变)、非手术治疗(基础治疗和药物治疗)以及手术治疗(修复性手术和重建手术)等管理措施。本文基于《中国髌股关节骨关节炎诊疗指南(2020年版)》,对PFOA诊疗相关的热点问题进行解读。     

Clinical practice guidelines for rest orthosis,knee sleeves,and unloading knee braces in knee osteoarthritis

ObjectiveTo develop clinical practice guidelines concerning the use of bracing – rest orthosis, knee sleeves and unloading knee braces – for knee osteoarthritis.MethodsThe French Physical Medicine and Rehabilitation Society (SOFMER) methodology, associating a systematic literature review, collection of everyday clinical practice, and external review by multidisciplinary expert panel, was used.ResultsFew high-level studies of bracing for knee osteoarthritis were found. No evidence exists for the effectiveness of rest orthosis. Evidence for knee sleeves suggests that they decrease pain in knee osteoarthritis, and their use is associated with subjective improvement. These actions do not appear to depend on a local thermal effect. The effectiveness of knee sleeves for disability is not demonstrated for knee osteoarthritis. Short- and mid-term follow-up indicates that valgus knee bracing decreases pain and disability in medial knee osteoarthritis, appears to be more effective than knee sleeves, and improves quality of life, knee proprioception, quadriceps strength, and gait symmetry, and decreases compressive loads in the medial femoro-tibial compartment. However, results of response to valgus knee bracing remain inconsistent; discomfort and side effects can result. Thrombophlebitis of the lower limbs has been reported with the braces. Braces, whatever kind, are infrequently prescribed in clinical practice for osteoarthritis of the lower limbs.ConclusionModest evidence exists for the effectiveness of bracing – rest orthosis, knee sleeves and unloading knee braces – for knee osteoarthritis, with only low level recommendations for its use. Braces are prescribed infrequently in French clinical practice for osteoarthritis of the knee. Randomized clinical trials concerning bracing in knee osteoarthritis are still necessary.     

MicroRNA基因调控在膝骨关节炎发生发展作用中的研究进展

MicroRNA(miRMA)是一种从哺乳动物细胞内发现的非编码小分子RNA,在基因的表达调控中起到了非常重要的作用,特别是转录后调节机制方面。近年来,miRNA在疾病发生发展过程中的作用已经成为研究热点。膝骨关节炎是一种常见的老年性疾病,其病因及发病机制至今尚未完全明确,目前细胞因子通过调节炎症反应,成骨破骨细胞增值、凋零、分化在膝骨关节炎发病机制中的作用越来越受到关注。而最新的研究表明,炎性介质、成骨破骨细胞增殖分化及各种细胞因子的转录表达都与miRNA有着密切的关联,这提示miRNA在膝骨关节炎的发生发展中起重要作用。由此可以想到,通过改变相关miRNA的表达可能会从更高的调节水平改变膝骨关节炎的表达,从而起到了治疗的目的。本文正是基于MicroRNA基因调控,探讨膝骨关节炎的发病机制,为临床提供更多的治疗思路。     

Usefulness of taping in lower limb osteoarthritis. French clinical practice guidelines

ObjectivesTo develop clinical practice guidelines about the use of taping in the management of lower limb osteoarthritis.MethodWe used the methodology advocated by the SOFMER (French Society for Physical and Rehabilitation Medicine), which combines a literature review, collection of data on current practice patterns, and validation of the recommendations by a multidisciplinary panel of experts. Our evaluation focused on the effectiveness of taping in relieving symptoms of lower limb osteoarthritis.ResultsAnkle taping for osteoarthritis is not recommended, given the absence of published data and very low level of use in France. Few studies are available on knee taping for osteoarthritis.ConclusionsPublished studies exhibit a number of methodological weaknesses. There is no strong evidence that taping is effective in knee osteoarthritis, and this treatment modality is rarely used in France. Therefore, there is no strong basis at present for recommending taping as part of the management of knee osteoarthritis. Well-designed studies of patellar taping to modify the relationships between the patellar and the trochlea are desirable to determine whether this treatment modality benefits patients with knee osteoarthritis, most notably those with involvement of the femoropatellar compartment.     

Evidence-based medicine, part 6. An introduction to critical appraisal of clinical practice guidelines

This article provides an introductory step-by-step process to appraise clinical practice guidelines. The authors introduce these principles using a systematic approach and case-based format. The process of assessing the validity of clinical practice guidelines, determining their importance, and applying them to an individual patient is reviewed. The concepts of study population homogeneity, equal treatment, and study completeness are discussed to help physicians determine the validity of clinical practice guidelines. Finally, information that is learned from the previously mentioned steps is applied to patient care. Study generalizability and the role of patient values, expectations, and concerns are also addressed. The skills learned from appraising clinical practice guidelines in the manner outlined provides a solid basis for life-long learning and improved patient care.     

Understanding pain in osteoarthritis

The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the 'phantom joint' as a cause for persistent pain after joint replacement.     

虎杖苷防治衰老相关骨代谢疾病研究

骨质疏松症及膝骨关节炎是临床上常见的衰老相关的骨代谢疾病，其发病率随年龄的增长而逐级攀升。虎杖苷是存在于中药虎杖中的一种天然多酚非黄酮类化合物，因其具有较强的调节骨代谢、促血管形成等作用而备受关注。本文通过总结相关文献，重点综述了虎杖苷的药代动力学特点及其在骨质疏松症和膝骨关节炎防治中的相关作用机制与靶点，以期为后续虎杖苷防治衰老相关骨代谢疾病的研究提供更多线索，为虎杖苷的开发利用提供更多的科学理论依据。     

关节腔内注射治疗膝骨关节炎的研究进展

近年应用关节腔内注射药物治疗膝骨关节炎(KOA)一直存在争议。国内外出版过多部指南,对于关节腔内注射药物的推荐强度是不同的,有的甚至相互矛盾,造成广大临床工作者对于这类治疗心存顾虑与疑惑;且缺少国内针对关节腔内注射药物的大样本数据,一定程度上限制了基于国人临床数据产生循证医学指南的可能。随着与国际骨科的接轨,我国学者们越来越重视循证医学指南的产生,在尚缺乏国人临床数据的前提下,试图通过多项专家共识的产生来呼吁更高级别的基础、临床研究的产生,以期更好地服务临床,服务患者。     

Understanding thoracic surgeons' perceptions of administrative database analyses and guidelines in clinical decision-making

ObjectivesThis study explored cardiothoracic surgeons' perceptions of health services research and practice guidelines, particularly how both influence providers' clinical decision-making.MethodsA trained interviewer conducted open-ended, semistructured phone interviews with cardiothoracic surgeons across the United States. The interviews explored surgeons' experiences with lung cancer treatment and their perceptions of health services research and guidelines. Researchers coded the transcribed interviews using conventional content analysis. Interviews continued until thematic saturation was reached.ResultsThe 27 surgeons interviewed mostly were general thoracic surgeons (23/27) who attend tumor board weekly (21/27). Five themes relating to physician perceptions of health services research and guidelines emerged. Databases analyses' inherent selection bias and perceived deficit of pertinent clinical variables made providers skeptical of using these studies as primary decision drivers; however, providers thought that database analyses are useful to supplement other data and drive future research. Likewise, providers generally felt that although guidelines provide a useful framework, they often have difficulty applying guidelines to individual patients. An analysis of provider characteristics revealed that younger physicians in practice for fewer years appeared more likely to report using guidelines, and physicians who were aged 50 years or more and not purely academic surgeons appeared to find database analyses less impactful.ConclusionsHealth services research, including database analyses, comprise much of the surgical literature; however, this study suggests that perceptions of database analyses and guidelines are mixed and questions whether thoracic surgeons routinely use either to inform their decisions. Researchers must address how to present compelling data to influence clinical practice.     

运动治疗膝骨关节炎的实施方案及临床探索

骨关节炎是一种关节软骨退行性疾病,伴有软骨下骨损伤。膝关节骨关节炎是发生于膝关节的骨关节炎,它符合骨关节炎的共同特点,同时具有膝关节这特殊部位的特点,随着社会老龄化,膝关节骨关节炎患者数量不断增加,将成为第一个严重威胁老年人健康的慢性疾病。近年来,运动疗法已被证明对骨关节炎有益,国内外相关指南中都不同程度地推荐运动疗法。基于本研究团队临床运动治疗经验以及现有的文献证据以归纳总结并分享相关经验及具体治疗措施,以期提供适合国人的运动治疗膝关节骨关节炎的标准化方案。