胰腺癌治疗的Cochrane系统评价证据

目的评价胰腺癌治疗的Cochrane系统评价证据,以及纳入系统评价的临床随机对照试验（RCT）的方法学质量。方法检索Cochrane Library数据库（2009年第4期）中有关胰腺癌治疗的系统评价,并运用RewMan5.0.21对所纳入研究的偏倚进行评估。结果共检索到胆道支架置入术姑息治疗梗阻型胰腺癌的系统评价、放化疗治疗不能手术的进展期胰腺癌的系统评价共2篇系统评价,共纳入79个RCT。依照Cochrane协作网推荐的质量评价方法,对所纳入RCT的偏倚进行评估,表明均存在不同程度的偏倚,方法学质量普遍较低。结论 Cochrane系统评价是公认的最高质量的研究证据,但目前缺少足够强度的证据来支持胆道支架置入术姑息治疗梗阻型胰腺癌的疗效。其他治疗手段的疗效如胰腺癌围手术期的营养支持治疗等还需要通过进一步的完成系统评价来评估。建议推行临床试验透明化,实施临床试验注册制度以及按照CONSORT声明严格规范RCT的报告,以便于总结胰腺癌治疗的临床证据。     

非布索坦治疗痛风疗效及安全性的Meta分析

目的：系统评价非布索坦治疗痛风的疗效及安全性。方法：计算机检索PubMed、EMBASE、SCI、CBM、CNKI、VIP、万方数据库及Cochrane图书馆,手工补充检索;纳入非布索坦治疗痛风的随机对照试验（RCT）;进行方法学质量评价和Meta分析。结果：共纳入3个RCT（受试者1985例）,A级文献1篇,B级文献2篇。Meta分析结果显示：最后3月血清尿酸（SU）持续低于6.0mg/dl患者数、随访结束时SU低于6.0mg/dl患者数非布索坦组与对照组差异均有统计学意义;治疗相关不良事件发生数与安慰剂组差异无统计学意义,与别嘌呤组差异有统计学意义。结论：基于当前证据,非布索坦治疗痛风,能有效降低SU含量,减少治疗相关不良事件发生率。     

口腔卫生护理的Cochrane系统评价证据

目的总结有关口腔卫生护理的Cochrane系统评价证据。方法计算机检索Cochrane Library（2008年第3期）中有关口腔卫生护理的系统评价,并进行分析。结果共检索到4篇系统评价,内容涉及：手动与电动牙刷对维护口腔卫生的效果比较,应用牙问隙刷保持固定矫治患者口腔卫生的效果评价,初级121腔卫生护理的复诊间隔的选择,刮舌预防口臭的效果。结论目前缺乏高强度证据来支持牙间隙刷等口腔卫生护理的疗效。其他口腔护理方法的疗效如漱口水等尚需通过进一步的试验来评估。现有口腔卫生护理的系统评价纳入随机对照试验的方法学质量普遍较低,部分研究存在随机方法描述不清、无隐蔽分组、无样本量计算,以及无意向治疗分析等缺陷。建议推行临床试验透明化,实施临床试验注册制度,按照CONSORT声明规范报道随机对照试验,以便总结口腔卫生护理的临床证据,提高口腔卫生护理临床水平。     

肾移植术后低剂量他克莫司免疫抑制治疗的Meta分析

目的评价肾移植术后他克莫司（TAC）低剂量对比常规剂量干预的疗效和安全性。方法检索MEDLINE、EMbase、SCI、CBM、Cochrane图书馆,纳入肾移植术后TAC低剂量对比常规剂量免疫抑制治疗的随机对照试验（RCT）。检索时间从各个数据库建库至2009年12月,对纳入研究进行方法学质量评价和Meta分析。结果纳入3个RCT,其中A级研究2个,B级研究1个。分析结果显示：两组急性排斥反应发生率比较,无统计学意义[RR=1.39,95%CI（0.64,3.01）];肾小球滤过率、受者/移植物生存率和纳入分析的安全性指标差异均无统计学意义。结论基于当前临床证据,肾移植术后TAC低剂量与常规剂量干预相比,近期疗效和安全性相似;远期结果尚需进一步研究探讨。     

青蒿琥酯治疗重症疟疾随机对照试验的系统评价

目的系统评价与其它药物比较,青蒿琥酯注射剂与栓剂治疗重症疟疾是否能降低患者病死率和改善其他临床结局。方法计算机检索Cochrane图书馆(2007年第3期)、MEDLINE(1966～2007.4)、EMbase(1988～2007.4)、CBMweb(1978～2007.4)、VIP(1989～2007.4)和CNKI(1994～2007.4)数据库,收集所有青蒿琥酯注射剂与栓剂治疗重症疟疾的随机对照试验(RCT),使用Cochrane系统评价方法,评价纳入研究的方法学质量并提取有效数据进行分析。结果共纳入11个RCT,共2269例患者。根据Cochrane图书馆推荐的RCT质量评价标准,各纳入研究的方法学质量均较高,6篇为A级,5篇为B级。其中6个RCT比较静脉注射用青蒿琥酯与静脉注射用奎宁的疗效,结果显示病死率差异有统计学意义[RR0.65,95%CI(0.52,0.80),P<0.0001],静脉注射用青蒿琥酯的疗效优于静脉注射用奎宁。3个RCT比较了静脉注射用青蒿琥酯与青蒿素栓的疗效,结果显示病死率差异无统计学意义,其RR及95%CI分别为0.94(0.35,2.56),0.58(0.19,1.74)和2.00(0.39,10.26)。2个RCT比较静脉注射和肌肉注射用青蒿琥酯的疗效,差异无统计学意义[RR1.50,95%CI(0.52,4.31),P=0.45]。静脉注射用青蒿琥酯与静脉注射用氯喹、蒿甲醚等其它药物比较,其病死率差异均无统计学意义。9个RCT报告了治疗后的不良反应,主要为轻微胃肠道反应,恶心、呕吐等。结论与奎宁比较,注射用青蒿琥酯更有效且副作用发生率明显降低;静脉用青蒿琥酯与肌肉用青蒿琥酯比较,以及静脉用青蒿琥酯与青蒿素栓比较,在病死率方面差异均无统计学意义。     

长托宁用于全身麻醉前用药的有效性评价

目的系统评价长托宁作为全身麻醉前用药是否能减少呼吸道粘液分泌和维持心率稳定。方法计算机检索Cochrane图书馆（2007年第3期）、MEDLINE（1966—2007．4）、EMbase（1988～2007．4）、CBMweb（1978～2007．4）、VIP（1989～2007．4）和CNKI（1994～2007．4），收集所有长托宁用于全身麻醉前用药的随机对照试验（RCT），使用Cochrane系统评价方法，评价纳入研究的方法学质量并提取有效数据进行分析。结果共纳入23个RCT，共2790例患者。各纳入研究的方法学质量均为B级，仅1篇文献正确描述了随机分配方法。其中11个RCT比较了长托宁与阿托品作为全身麻醉前用药的疗效，但仅2个RCT比较了术毕气道分泌物量的差异，结果显示差异有统计学意义[WMD=-8．00，95％CI（-8．16，-7．85），P〈0．00001]，长托宁作为术前用药可以有效减少呼吸道粘液分泌。12个RCT比较了长托宁与东莨菪碱的疗效，但仅2个RCT比较了术毕气道分泌物量的差异，结果显示差异无统计学意义[WMD=-17．07，95％CI（-45．49，11．35），P=0．24]。3个RCT比较了长托宁和安慰剂的疗效，结果显示差异有统计学意义[WMD=-10．60，95％CI（-13．64，-7．56），P〈0．00001]。尚未检索出比较长托宁不同剂量用于全身麻醉前用药的文献。7个RCT报告了用药后的不良反应，未发现严重不良反应。结论与阿托品比较，长托宁能有效减少呼吸道粘液分泌且副作用发生率明显较低；与东莨菪碱比较，长托宁疗效与东莨菪碱相似；与不用药比较，长托宁效果明显。但因证据强度较低，本系统评价结论尚需更多高质量RCT进一步论证。     

肾移植术后低剂量与常规剂量环孢素A比较进行免疫抑制治疗有效性与安全性的Meta分析

目的系统评价肾移植术后环孢素A低剂量与常规剂量比较的免疫抑制效果和安全性。方法计算机检索MEDLINE、EMbase、SCI、CBM、Cochrane图书馆检索时间均从建库至2009年12月,纳入肾移植术后环孢素A低剂量与常规剂量比较进行免疫抑制治疗的随机对照试验（RCT）。在评价纳入研究的方法学质量和提取有效数据后,采用RevMan5.0进行Meta分析。结果共纳入6个RCT,包括1551例患者,质量评价结果显示4个研究为A级、2个为B级。Meta分析结果显示：随访6个月及12个月两组急性排斥反应发生率[RR=1.07,95%CI（0.69,1.65）;RR=1.06,95%CI（0.71,1.57）]、受者病死率[RR=0.64,95%CI（0.20,2.03）;RR=0.61,95%CI（0.30,1.24）];以及移植物丢失率[RR=0.72,95%CI（0.38,1.36）;RR=0.82,95%CI（0.54,1.25）]差异均无统计学意义,肾脏功能及纳入分析的安全性指标差异均无统计学意义。结论基于当前临床证据,肾移植术后CsA低剂量与常规剂量相比,近期疗效和安全性相似;远期结果有待进一步研究探讨。     

中药配合三阶梯止痛治疗癌痛随机对照试验的Meta分析

目的：评价中药配合三阶梯止痛与单纯三阶梯止痛比较治疗癌性疼痛的有效性和安全性。方法：采用Cochrane系统评价方法,计算机检索Cochrane图书馆临床对照试验资料库、MEDLINE、CBM、CNKI、VIP和万方;同时手检相关期刊和会议论文集,纳入有关中药配合三阶梯止痛治疗癌性疼痛的随机对照试验,并按Cochrane系统评价员手册4．2．2版推荐的质量评价标准评价纳入研究质量,对同质的研究进行Meta分析。结果：共检索到符合纳入标准的中文文献12篇（1366例患者）。文献质量评价结果显示,所有文献均为C级。Meta分析结果显示,中药配合三阶梯止痛治疗癌痛在近期镇痛效果、提高生活质量和减少不良反应发生方面优于单纯三阶梯止痛药治疗。结论：中药配合三阶梯止痛治疗癌性疼痛优于单纯三阶梯止痛治疗。但由于纳入试验研究的方法学质量普遍较低,期待更多设计合理、方法科学的大样本多中心随机双盲对照临床试验,提供高质量的证据。     

中草药治疗乙型肝炎病毒无症状携带者的系统评价

目的 评价中草药治疗乙型肝炎病毒无症状携带的疗效与安全性。设计 Cochrane系统评价。研究的鉴定检索Cochrane肝胆疾病组、Cochrane图书馆、Cochrane另证医学领域试验注册数据,MEDLINE、EMBASE以及BIOSIS数据库。手工检索发表与未发表之中献。纳入标准 收集比较中草药与安慰剂、未治疗、非特异性治疗或干扰素治疗乙型肝炎病毒无症状携带并随访达3个月以上的随机临床试验。试验无论是否使用盲法或发表语种均不受纳入限制。资料提取与统计方法 两名评价人员独立提取资料。 纳入试验的方法学质量采用Jadad评分标准与随机分配隐藏。数据采用Cochrane协作网专用软件RevMan4．1版进行统计分析。结果 3篇共涉及307名病人随访达3个月及以上的随机临床试验符合纳入标准。均为低质量试验。健脾温肾方与干扰素比较对清除乙型肝炎病毒具有显效果：清除乙型肝炎病毒血清表面抗原（HBsAg）相对危险度为2．40（95％可信区间1．01－5．72）,血清e抗原（HBeAg)转化为e抗体的效应为2．54（1．13－5．70）。草药叶下珠和黄芪与安慰剂比较未见显的抗病毒效果。对8个随访少于3个月的随机临床试验的分析表明中草药对病毒标志物无显疗效。试验未发现严重的副作用。结论 由于小样本及低质量的随机对照试验,中草药治疗乙型肝炎病毒携带的证据无够充分。需要进一步的随机双盲安慰剂对照试验。     

中药治疗心房颤动的系统评价再评价

目的对中药治疗心房颤动的系统评价进行再评价。方法计算机检索PubMed、The Cochrane Library、EMbase、CNKI、CBM、WanFang Data和VIP数据库,搜集中药治疗心房颤动的系统评价(SR),检索时限均为建库至2019年7月。由2名研究员独立筛选和提取资料后,应用AMSTAR2量表、PRISMA声明和GRADE方法对纳入研究的方法学质量、报告质量和证据质量进行评价。结果最终纳入20个SR,其中15个合并分析了临床疗效,12个对不良反应进行了分析。纳入SR的AMSTAR2方法学质量评价整体偏低,评价为高质量的0篇,低质量1篇,极低质量19篇;得分较差的条目为条目2、7、8、9、10、12、13、14、16。纳入SR的PRISMA得分在14~22.5分之间,报告质量问题主要表现在方案与注册、资料条目、其他分析方法和资金来源方面。采用GRADE进行结局指标证据体评价,证据体质量普遍较低。结论中药治疗房颤可提高临床疗效,减少不良反应,但所纳入文献整体方法学质量不高,证据体质量普遍偏低,建议进一步开展高质量临床研究,为评价中药治疗房颤临床疗效提供依据。     

Pharmacotherapy of orofacial pain

OBJECTIVES. Pharmacotherapy of chronic orofacial pain is unsatisfactory. Here we set out to prepare a systematic review of randomized controlled clinical trials (RCTs) on pharmacotherapy of facial pain. METHODS. The diagnostic groups "temporomandibular disorders" (TMDs), "atypical facial pain", and "trigeminal neuralgia" were included. RCTs published between 1966 and August 2001 were identified by Medline search, from review articles, and from the Cochrane and Bandolier databases. The quality of the trials was judged according to established criteria. Good or excellent pain reduction or >50% pain reduction were used as endpoints for successful treatment. Numbers needed to treat (NNTs) and their 95% confidence intervals were calculated where dichotomous data were available. RESULTS. Twelve studies were identified for the TMDs, 11 for trigeminal neuralgia, four for atypical facial pain. Many studies had methodological problems and small numbers of patients. There was sufficient evidence of efficacy of carbamazepin in trigeminal neuralgia, also for baclofen and lamotrigine. In the TMD studies, there was evidence of a moderate effect of muscle relaxants/tranquilizers. Two studies of atypical facial pain showed a moderate effect of antidepressants. CONCLUSIONS. Apart from studies in trigeminal neuralgia, there is little evidence of efficacy of pharmacotherapy in orofacial pain. High quality studies with sufficient numbers of patients using operational definitions of disease entities are warranted.     

Total glucosides of paeony for rheumatoid arthritis: A systematic review of randomized controlled trials

BackgroundTotal glucosides of paeony (TGP) is commonly used to treat rheumatoid arthritis (RA) in China. However, clinical practice hasn’t been well informed by evidence from appropriately conducted systematic reviews. This PRISMA-compliant systematic review aims at examining the effectiveness and safety of TGP for RA.MethodsRandomized controlled trials (RCTs) comparing TGP with placebo, no treatment, or disease-modifying antirheumatic drugs (DMARDs) for patients with RA were retrieved by searching seven databases. Primary outcomes included disease improvement and disease remission. Secondary outcomes included adverse effects, pain, health-related quality of life, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Data extraction and analyses were conducted according to the Cochrane standards. We assessed risk of bias for each included studies and quality of evidence on pre-specified outcomes.ResultsEight studies enrolling 1209 patients with active RA were included in this systematic review. On the basis of traditional DMARD(s), TGP might be beneficial for patients with RA in improvement of American College of Rheumatology (ACR) 20 response rate, ACR 50 response rate, ACR70 response rate, and in reduction of adverse effects, compared with no treatment. The overall methodological quality of included studies and the quality of evidence for each outcome were limited.ConclusionsCurrent trials suggested potential benefits of TGP for RA on the basis of traditional DMARD(s). Therefore, TGP may be a good choice for RA as an adjuvant therapy. However, considering the limited methodological quality and strength of evidence, high-quality RCTs are warranted to support the use of TGP for RA.     

一例新生儿胎粪吸入综合征合并肺动脉高压的循证治疗

目的探讨新生儿胎粪吸入综合征合并肺动脉高压的循证治疗方法。方法针对患儿的临床问题,以肺动脉高压、新生儿、胎粪吸入综合征、治疗为主题词和自由词,计算机检索Cochrane图书馆（2009年第2期）、MEDLINE（1980～2009．6）、ACP Journal Club（1991年1月～2009年9月）和中国期刊全文数据库（1994～2009年6月）,查找相关的系统评价、随机对照试验和临床回顾性研究等,并评价所获证据的质量和适用性。结果共纳入2个系统评价、1个Meta分析,9个随机对照试验和1个卫生经济学评价。所获证据显示：①使用体外膜肺治疗可减少患儿的病死率,但会增加治疗成本;②吸入一氧化氮可显著升高患儿的动脉血氧分压、减少使用体外膜肺;③目前尚无评价过度通气、高频通气、控制性碱血症、扩血管药物（硫酸镁、妥拉苏林、前列腺素与前列环素、米力农）及肺表面活性物质治疗新生儿持续肺动脉高压临床效果的随机对照试验;④口服西地那非可降低持续肺动脉高压患儿的氧合指数,降低住院期间患儿的病死率。结合医院现有条件、患儿情况及其家属的意愿,口服西地那非治疗后患儿给氧浓度降低,逐渐撤离呼吸机,一般情况可,1个月后治愈出院。结论采用循证治疗方法,为胎粪吸入综合征合并肺动脉高压的新生儿制定合理的治疗方案,可有效提高治疗效果,提高患儿生存率。     

微波治疗宫颈糜烂随机对照试验的质量评价

目的评价微波治疗宫颈糜烂随机对照试验的方法学质量和报告质量。方法通过计算机检索、手工检索,全面收集与微波治疗宫颈糜烂有关的随机对照试验,按照Cochrane协作网推荐的评价方法对纳入研究进行方法学质量评价,按照CONSORT清单项目进行研究报告质量评价。结果最终纳入文献11篇,其中随机对照试验3篇,半随机对照试验8篇。评价结果显示,纳入文献方法学质量和报告质量普遍较低,其中C级为10篇, CONSORT评分最高仅17分。结论以往的微波治疗宫颈糜烂随机对照试验研究存在不同程度的方法学质量缺陷,故其结论存在发生选择性偏倚、实施性偏倚、测量性偏倚以及减员性偏倚的高度可能性。而低的研究报告质量又会严重影响读者对研究结果真实性、重要性及实用性的正确理解和评价。因此期待设计严密、实施科学、报告完整的随机对照研究出现。     

A systematic review of conservative treatment of carpal tunnel syndrome

OBJECTIVE: To assess the effectiveness of conservative therapy in carpal tunnel syndrome. DATA SOURCES: A computer-aided search of MEDLINE and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) from January 1985 to May 2006. REVIEW METHODS: RCTs were included if: (1) the patients, with clinically and electrophysiologically confirmed carpal tunnel syndrome, had not previously undergone surgical release, (2) the efficacy of one or more conservative treatment options was evaluated, (3) the study was designed as a randomized controlled trial. Two reviewers independently selected the studies and performed data extraction using a standardized form. In order to assess the methodological quality, the criteria list of the Cochrane Back Review Group for systematic reviews was applied. The different treatment methods were grouped (local injections, oral therapies, physical therapies, therapeutic exercises and splints). RESULTS: Thirty-three RCTs were included in the review. The studies were analysed to determine the strength of the available evidence for the efficacy of the treatment. Our review shows that: (1) locally injected steroids produce a significant but temporary improvement, (2) vitamin B6 is ineffective, (3) steroids are better than non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics, but they can produce side-effects, (4) ultrasound is effective while laser therapy shows variable results, (5) exercise therapy is not effective, (6) splints are effective, especially if used full-time. CONCLUSION: There is: (1) strong evidence (level 1) on efficacy of local and oral steroids; (2) moderate evidence (level 2) that vitamin B6 is ineffective and splints are effective and (3) limited or conflicting evidence (level 3) that NSAIDs, diuretics, yoga, laser and ultrasound are effective whereas exercise therapy and botulinum toxin B injection are ineffective.     

Occlusal treatments in temporomandibular disorders: a qualitative systematic review of randomized controlled trials

Occlusal treatments (occlusal splints and occlusal adjustment) are controversial but widely used treatment methods for temporomandibular disorders (TMD). To investigate whether studies are in agreement with current clinical practices, a systematic review of randomized controlled trials (RCTs) of occlusal treatment studies from the period 1966 to March 1999 was undertaken. Eighteen studies met the inclusion criteria, 14 on splint therapy, and 4 on occlusal adjustment. The trials were scored using the quality scale presented by Antczak et al., 1986a (A.A. Antczak, J. Tang, T.C. Chalmers, Quality assessment of randomized control trials in dental research. I. Methods, J. Periodontal Res. 1986a;21:305-314). The overall quality of the trials was fairly low, the mean quality score was 0.43/1.00 (range 0.12-0.78). The most obvious methodological shortcomings were inadequate blinding, small sample sizes, short follow-up times, great diversity of outcome measures and numerous control treatments, some of unknown effectiveness. Splint therapy was found superior to 3, and comparable to 12 control treatments, and superior or comparable to 4 passive controls, respectively. Occlusal adjustment was found comparable to 2 and inferior to one control treatment and comparable to passive control in one study. Because of the methodological problems, only suggestive conclusions can be drawn. The use of occlusal splints may be of some benefit in the treatment of TMD. Evidence for the use of occlusal adjustment is lacking. There is an obvious need for well designed controlled studies to analyse the current clinical practices.     

Transcendental meditation for lowering blood pressure: An overview of systematic reviews and meta-analyses

BackgroundTranscendental meditation (TM) is a stress reduction technique that can potentially lower blood pressure (BP) safely. The American Heart Association recommends that TM may be considered in clinical practice.ObjectiveTo provide an overview of all systematic reviews and meta-analyses of TM on BP for evidence-informed clinical decision making.MethodSystematic searches of PubMed, EBSCOhost, Cochrane Library, Web of Science, Embase, and PsycINFO for all systematic reviews and/or meta-analyses of randomized controlled trials (RCTs) with TM as an intervention, and outcome measures include systolic BP (SBP) and diastolic BP (DBP). Qualitative and quantitative data were synthesized. The methodological quality of the selected reviews was assessed using the AMSTAR checklist.ResultsEight systematic reviews and meta-analyses are included. Among them is an Agency for Healthcare Research and Quality report, a Cochrane systematic review, 4 independent reviews, and 2 reviews from a TM related institution. The quality of most of the included reviews is fair with a mean score of 5.75/11 on the AMSTAR scale. Overall, there exists a clear trend of increasing evidence over the years supporting the efficacy of TM in lowering BP. However, some conflicting findings remain across reviews and potential risk of bias exists in many of the RCTs included in these reviews.ConclusionPractising TM may potentially reduce the SBP by ∼4 mm Hg and DBP by ∼2 mm Hg. Such effect is comparable with other lifestyle interventions such as weight-loss diet and exercise. Further evidence from long-term well-designed RCTs conducted by independent researchers is needed.     

Static body postural misalignment in individuals with temporomandibular disorders: a systematic review

BACKGROUND:

The association between body postural changes and temporomandibular disorders (TMD) has been widely discussed in the literature, however, there is little evidence to support this association.

OBJECTIVES:

The aim of the present study was to conduct a systematic review to assess the evidence concerning the association between static body postural misalignment and TMD.

METHOD:

A search was conducted in the PubMed/Medline, Embase, Lilacs, Scielo, Cochrane, and Scopus databases including studies published in English between 1950 and March 2012. Cross-sectional, cohort, case control, and survey studies that assessed body posture in TMD patients were selected. Two reviewers performed each step independently. A methodological checklist was used to evaluate the quality of the selected articles.

RESULTS:

Twenty studies were analyzed for their methodological quality. Only one study was classified as a moderate quality study and two were classified as strong quality studies. Among all studies considered, only 12 included craniocervical postural assessment, 2 included assessment of craniocervical and shoulder postures,, and 6 included global assessment of body posture.

CONCLUSION:

There is strong evidence of craniocervical postural changes in myogenous TMD, moderate evidence of cervical postural misalignment in arthrogenous TMD, and no evidence of absence of craniocervical postural misalignment in mixed TMD patients or of global body postural misalignment in patients with TMD. It is important to note the poor methodological quality of the studies, particularly those regarding global body postural misalignment in TMD patients.