缺血性卒中药物防治相关中国指南的系统评价

目的 评价近5年已发布的中国缺血性卒中药物防治相关指南的证据和推荐意见。 方法 计算机检索国内平台（中国生物医学网、知网、万方等）和国外平台（Pubmed、NGC、GI N等），检 索时限为2012年1月-2017年5月。运用临床指南研究与评估系统Ⅱ（AGREEⅡ）评价纳入指南的方法学 质量，并分析综述不同指南的证据水平与推荐强度。 结果 共纳入19篇指南，在AGREEⅡ 6个领域（范围和目的、参与人员、严谨性、清晰性、应用性、独 立性）的平均得分率分别为60%、19%、26%、55%、23%、2%。结合各指南的推荐意见和证据等级，目 前静脉溶栓药物的有效时间窗仍在超早期内（＜4.5 h），溶栓适应证增多是否获益尚不明确。对于轻 型卒中，不同指南均推荐双抗药物治疗方案。心源性卒中的抗凝启动时机仍是各指南间争议最大的 部分。缺血性卒中的血压控制应首要遵循个体化原则。神经保护剂的疗效仍需大量临床试验的证实。 结论 本领域指南体现了临床实践中的难点和热点，为临床一线医生更好地应用指南指导药物防 治缺血性卒中提供指导。但指南的总体质量不高，未来需要进一步提高指南制定的方法学质量。     

单纯疱疹病毒性脑炎治疗措施的临床证据评价

目的评价不同治疗方案对单纯疱疹病毒性脑炎的作用及不良反应,以为循证制定最佳治疗方案。方法以脑炎、病毒性脑炎、单纯疱疹病毒、抗病毒治疗、肾上腺皮质激素、治疗等词组作为检索词,分别检索MEDLINE、Cochrane图书馆、万方数据知识服务平台学术期刊库和中国知网中国期刊全文数据库,并辅以手工检索,获取临床指南、系统评价、随机对照试验、临床对照试验及病例观察研究的相关文献,采用Jadad量表对文献质量进行评价。结果经筛选共纳入与单纯疱疹病毒性脑炎治疗有关的临床指南2篇、系统评价2篇、随机对照试验2篇、临床对照试验2篇、病例观察研究3篇;其中9篇被评为高质量文献（3篇Jadad量表评分为4分、5篇评分为5分、1篇评分为7分）,2篇为低质量文献（评分为3分）。对各种治疗方法的疗效及安全性评价显示：（1）抗病毒药物为单纯疱疹病毒性脑炎的首选治疗方法。（2）若病情不能缓解,应在充分评价肾上腺皮质激素利弊后考虑激素类药物治疗。（3）肾上腺皮质激素疗效欠佳者可考虑加用免疫治疗药物以缓解症状。（4）外科手术治疗不作为推荐治疗方法,唯有在颅内压过高的情况下方考虑施行手术减压。结论借助循证医学评价方法可为单纯疱疹病毒性脑炎患者的治疗提供最佳临床证据。     

单纯疱疹病毒性脑炎治疗措施的临床证据评价

目的评价不同治疗方案对单纯疱疹病毒性脑炎的作用及不良反应,以为循证制定最佳治疗方案。方法以脑炎、病毒性脑炎、单纯疱疹病毒、抗病毒治疗、肾上腺皮质激素、治疗等词组作为检索词,分别检索MEDLINE、Cochrane图书馆、万方数据知识服务平台学术期刊库和中国知网中国期刊全文数据库,并辅以手工检索,获取临床指南、系统评价、随机对照试验、临床对照试验及病例观察研究的相关文献,采用Jadad量表对文献质量进行评价。结果经筛选共纳入与单纯疱疹病毒性脑炎治疗有关的临床指南2篇、系统评价2篇、随机对照试验2篇、临床对照试验2篇、病例观察研究3篇;其中9篇被评为高质量文献(3篇Jadad量表评分为4分、5篇评分为5分、1篇评分为7分),2篇为低质量文献(评分为3分)。对各种治疗方法的疗效及安全性评价显示:(1)抗病毒药物为单纯疱疹病毒性脑炎的首选治疗方法。(2)若病情不能缓解,应在充分评价肾上腺皮质激素利弊后考虑激素类药物治疗。(3)肾上腺皮质激素疗效欠佳者可考虑加用免疫治疗药物以缓解症状。(4)外科手术治疗不作为推荐治疗方法,唯有在颅内压过高的情况下方考虑施行手术减压。结论借助循证医学评价方法可为单纯疱疹病毒性脑炎患者的治疗提供最佳临床证据。     

影响病毒性脑炎预后的因素

病毒性脑炎是指病毒感染所引起的脑实质的炎症。通常指急性非流行性病毒性脑炎(病脑)，主要包括疱疹病毒性脑炎和肠道病毒性脑炎，如单纯疱疹病毒性脑炎(HSE)、巨细胞病毒性脑炎、EB病毒性脑炎、水痘．带状疱疹病毒性脑炎等。每年美国单是HSE就有2万人发病。虽然不如脑卒中和脑外伤常见，但仍然是致死、致残的重要原因之一。病脑患者的     

关于带状疱疹抗病毒治疗的点滴体会

带状疱疹是水痘带状疱疹病毒引起的急性疱疹性皮肤病。临床上以疱疹和神经痛为主要症状。基层门诊常使用阿昔洛韦（无环鸟苷）、利巴韦林（三氮唑核苷、病毒唑）、吗啉胍（ABOB、病毒灵）等抗病毒药物治疗此病。但笔者近年来在工作实践中发现使用上述抗病毒药物治疗带状疱疹效果屡屡不明显,举例如下。     

高氧液联合更昔洛韦治疗病毒性脑炎的疗效观察

目的 评价高氧液联合更昔洛韦治疗病毒性脑炎的疗效和安全性.方法 将61例成人病毒性脑炎患者随机分为治疗组和对照组,2组在降颅压、降温、支持等综合治疗基础上,治疗组每日静滴更昔洛韦10mg/(kg·d),分2次静滴,并加用高氧液一组;对照组每日静滴阿昔洛韦15mg/kg静滴,1次/d.疗程均为14d.结果 治疗组病毒性脑炎治愈率显著提高,差异有显著意义.结论 高氧液联用更昔洛韦治疗病毒性脑炎安全性高,疗效显著.     

急性缺血性卒中相关性肺炎的管理相关循证指南的AGREEⅡ质量评价

目的 评价预防急性缺血性卒中相关性肺炎相关指南的质量,为科学系统制定我国的临床指南提供参考.方法 按照纳入、排除标准纳入数据库及网站检索的国内外有关预防急性缺血性卒中相关性肺炎的临床指南,并按照国际公认的指南评价工具(Appraisal of Guidelines for Research and Evaluation...     

美国神经病学学会治疗和技术评价委员会关于静脉注射免疫球蛋白在神经肌肉疾病治疗中应用的循证指南

2012年3月27日Neurology杂志发表了美国神经病学学会(American Academy of Neurology,AAN)治疗和技术评价委员会关于静脉注射免疫球蛋白(IVIG)在神经肌肉疾病治疗中应用的循证指南[1]。通过检索1966-2009年间在MEDLINE、Web of Science和EMBASE数据库的资料,纳入涉及IVIG疗效、安全性、耐受性和治疗模式的文献,5位专家按照AAN证据级别评定后按照AAN的推荐级别提出循证建议(证据级别和推荐级别见该文章附件[1],本刊曾对其进行介绍[2])。     

美国国家卒中协会短暂性脑缺血发作处理指南

目的：短暂性脑缺血发作（TIA）是常见和重要的卒中先兆。其处理方法多样，大多数发表的指南在近年来均未被更新。我们试图制定一个全面的、无偏倚的、循证的TIA处理指南。方法：根据一种客观标准（可以预测在该研究领域中执业医师对专家提名的文献测量学方法）挑选出15名专家组成员。通过系统回顾检索到过去发表的指南，由专家对其中的推荐意见的质量进行独立评价。选择出质量最高的推荐意见，然后让专家组采用改良Delphi法通过多次问卷调查的方式进行修订，从而对新的修改达成共识。给专家们提供近期临床研究的系统评价，要求专家根据新的证据判断措辞修改的合理性并且根据证据等级和质量对最终的推荐意见进行评定。不允许专家在预期有可能存在任何利益冲突的专题方面提出推荐意见。结果：通过系统回顾检索到257个指南，其中有13篇文献包括的137条推荐意见符合所有纳入标准。需要6次重复的问卷调查对53条最终推荐意见的措辞达成共识。最终的推荐意见涉及TIA的初步处理、评价、内科治疗、外科治疗和危险因素控制。结论：对TIA患者医疗诊治的最终推荐意见强调了紧急评价和治疗的重要性。这种用于制定本指南的新方法是可行的，考虑到了快速更新并能减少偏倚。     

单纯疱疹病毒性脑炎发展简史

单纯疱疹病毒性脑炎是由单纯疱疹病毒引起的急性中枢神经系统感染性疾病,早期临床主要表现为发热、头痛、意识障碍,进展时可出现精神症状,若不及时治疗,可导致患者死亡或遗留严重的神经系统后遗症。随着实验室和影像学技术的发展,单纯疱疹病毒性脑炎的早期诊断越来越成为可能,其中影像学显示颞叶异常信号具有提示作用,而聚合酶链反应检测脑脊液中单纯疱疹病毒DNA则是目前诊断的"金标准"。应尽早予以阿昔洛韦治疗,延迟治疗可导致不良预后。     

European psychiatric treatment guidelines: is the glass half full or half empty?

PURPOSE: We assessed the quality of European treatment guidelines in the field of mental health that have been produced by national psychiatric associations. The main focus was the question of whether the development process of the guidelines followed basic principles of evidence-based medicine. METHODS: Sixty-one European clinical practice guidelines from 14 countries, published between 1998 and 2003, were assessed using the 'Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument'. The domain score was calculated for each of the six domains of the AGREE instrument. The seven items of the domain "rigor of development" and one additional item concerning national particularities were assessed in detail. RESULTS: The mean scores in the six domains were rather low, although the quality varied among the different guidelines. The highest mean score was obtained in the domain clarity and presentation (70.8% S.D. 23.5), the lowest on editorial independence (19.7% S.D. 29.3). The recommendations of about half of the assessed guidelines could be considered to be evidence-based. CONCLUSION: The assessed guidelines showed a broad range of quality: some producers attached importance to an evidence-based development process; but in spite of this, a large number of guidelines were only of middling quality. As national particularities are only rarely mentioned and the development process of guidelines is complex, an international collaboration that aims toward the production of shareable guidelines might be promising.     

Korean Clinical Practice Guideline for the Diagnosis and Treatment of Insomnia in Adults

Objective We aim to present a clinical guideline for the diagnosis and treatment of insomnia in adults by reviewing and integrating existing clinical guidelines. The purpose of this guideline is to assist clinicians who perform evidence-based insomnia treatment. Methods We selected literature that may be appropriate for use in guideline development from evidence-based practice guidelines that have been issued by an academic or governmental institution within the last five years. The core question of this guideline was made in sentence form including Patient/Problem, Intervention, Comparison, Outcome (PICO) elements. After searching PubMed, EMBASE, and medical guideline issuing agencies, three guidelines were judged to be the most appropriately reviewed, up-to-date, and from trusted sources. Results The Appraisal of Guidelines for Research and Evaluation (AGREE) II tool was used to evaluate the quality of the three clinical guidelines. The final outcome of the guideline development process is a total of 15 recommendations that report the strength of the recommendation, the quality of evidence, a summary of content, and considerations in applying the recommendation. Conclusion It is vital for clinical guidelines for insomnia to be developed and continually updated in order to provide more accurate evidence-based treatments to patients.     

Specific IgG subclass reactivity in herpes simplex encephalitis

Summary Serum and cerebrospinal fluid (CSF) samples from 19 patients with a previous diagnosis of herpes simplex virus encephalitis (HSVE), from 14 patients with a previous diagnosis of non HSVE encephalitis and from 21 healthy subjects were examined to detect IgG subclasses 1–4 reactive with herpes simplex virus (HSV), cytomegalovirus (CMV) and varicella zoster virus (VZV). Antibodies to HSV were detected in CSF and serum from the 14 HSVE-patients with a reactivated HSV infection and from 3 of the 5 patients with a primary HSV infection. The predominant subclass pattern was an early HSV-specific IgG1 rise, followed by IgG3 and, more seldom, IgG4; HSV IgG2 was rarely seen. In HSVE patients, HSV IgG3 was absent in early samples and usually appeared 10–20 days after onset of disease. In 14 out of 16 seropositive healthy controls, on the other hand, HSV IgG3 was present in the CSF. Rising VZV IgG levels in serum and CSF were found in 11 HSVE patients. Eight of them showed signs of intrathecal VZV IgG1 synthesis. The VZV IgG reactivity was restricted to IgG1 in 7 of these whereas the HSV IgG subclass response also included IgG3 or 4. The appearance of several HSV IgG subclasses appeared to serve as a marker of HSV infection in spite of the serological VZV reaction, usually restricted to VZV IgG1. Intrathecal synthesis of the quantitatively minor HSV IgG3 and 4 subclasses was detected earlier than intrathecal synthesis of total HSV IgG, dominated by IgG1 in 4 patients with HSVE.     

Herpes simplex encephalitis in childhood]

Central nervous system (CNS) infection by herpes simplex virus (HSV) in childhood consists of herpes simplex encephalitis and CNS infections in neonates. Herpes simplex encephalitis in children resembles that in adults, but CNS infections in neonates differs from adult herpes simplex encephalitis in pathogenesis and clinical features. Trans-neuronal transmission by HSV type 1 causes herpes simplex encephalitis both in children and adults, while hematogeneous spread by HSV type 1 or type 2 causes CNS infections in neonates. Mortality of CNS infections by HSV in childhood has been improved since early diagnosis by polymerase chain reaction and anti-viral therapies have been established. However, neurological morbidity has not yet been improved and sometimes HSV infections relapse after the acyclovir therapy. Recently, longer acyclovir therapy with larger doses is recommended for the treatment of CNS infections in childhood.     

Fine specificities of antibodies in sera and cerebrospinal fluid in herpes virus infections of the central nervous system as detected by the antigen variable immunoblot technique

Applying the immunoblot technique a sensitive and specific method was developed for the detection of intrathecally synthesized antibodies against individual specific proteins that are antigens of various infectious agents causing encephalitis. Paired serum and cerebrospinal fluid (CSF) samples from five patients with herpes virus infections of the central nervous system (CNS) (three herpes simplex virus encephalitis, one varicella zoster virus encephalitis, one zoster ganglionitis) were investigated for the presence of locally produced IgG against the electrophoretically separated antigens of herpes simplex virus (HSV), varicella zoster virus (VZV) and human cytomegalovirus (HCMV), as well as for IgM antibodies in one case of HSV encephalitis. In two cases (HSV encephalitis and VZV encephalitis) four and one antibody, respectively, were found that were synthesized intrathecally only. In the other cases the patterns of sera and CSF antibodies were similar, the CSF antibodies showing an all-over stronger reaction, at identical IgG concentrations. In contrast to the conception of a 'limited heterogeneity' of intrathecal antibody synthesis in encephalitis, we thus found an 'expanded heterogeneity' of the intrathecally synthesized antibodies in comparison to the corresponding serum antibodies.     

Absent anti-N-methyl-D-aspartate receptor NR1a antibodies in herpes simplex virus encephalitis and varicella zoster virus infections

Purpose: A 2012 report and subsequent case series described anti-N-methyl-D-aspartate receptor (NMDAR) antibodies in patients during the acute phase and relapse of herpes simplex virus 1 (HSV1) encephalitis (HSV1E). However, the prevalence of this phenomenon is unknown and systematic studies on other viral infections of the nervous system are missing. Materials and methods: We retrospectively analyzed serial cerebrospinal fluid (CSF) and serum samples of consecutive patients treated for neurological HSV1, HSV2 and varicella zoster virus (VZV) infections in our tertiary care university hospital between 2003 and 2013 for the presence of antibodies directed against the NR1a subunit of the NMDAR using indirect immunofluorescence. Results: In total, 88 patients with the following infections were identified through an electronic database search: HSV1 (24 with encephalitis), HSV2 (6 with meningitis, 3 with encephalitis and 1 with myelitis), or VZV (3 with meningitis, 33 with encephalitis, 17 with radiculitis and 1 with myelitis). Two patients with HSV1E and HSV2E, respectively, experienced a clinical relapse. Clinical follow-up was for up to 85 months, and repetitive serum and CSF analyses for up to 43 months. However, at no time did any of the 88 patients exhibit anti-NMDAR NR1a antibodies. Conclusions: In this study, we did not detect anti-NMDAR NR1a antibodies in serial CSF and serum samples of HSV1E patients or patients with other viral infections (HSV2 and VZV). However, the presence of antibodies directed against other epitopes of the NMDAR and other neuronal cell surface antigens cannot be excluded, necessitating further studies.     

Schizophrenia guidelines across the world: A selective review and comparison

Abstract

Treatment guidelines provide evidence-based recommendations to assist practitioners in specific clinical situations. They are a major tool to assure and enhance treatment quality and to overcome existing disparities. However, guideline quality itself varies and needs to be considered. Based on a former review, schizophrenia guidelines with high methodological quality were identified and examined regarding updated versions. Five guidelines were selected, of which three updates have been newly evaluated with the AGREE instrument. In addition, clinical content regarding seven core topics in schizophrenia treatment decisions was compared. Guideline quality on average is good, with highest AGREE scores for the NICE guideline. Updating of the German guideline resulted in noticeable quality improvements. Regarding content, recommendations largely correspond in five areas across guidelines, whereas discrepancies or vagueness exist in two areas due to newly emerging (drug choice) or still restricted evidence (duration of antipsychotic treatment). There are increasing efforts to develop guidelines with improved quality. Also, there is a need to equalize and improve healthcare quality across countries. Since many formal and content-related issues are ‘universal’, development of trans-national guidelines seems indicated. Nevertheless, core guideline recommendations should be adapted to regional conditions using available tools for adaptation.     

Infections of the central nervous system of suspected viral origin: a collaborative study from Finland

We studied 3231 patients with acute central nervous system (CNS) symptoms of suspected viral origin to elucidate the current etiologic spectrum. In 46% of the cases, a viral finding was observed. Varicella-zoster virus (VZV) was the main agent associated with encephalitis, as well as meningitis and myelitis. VZV comprised 29% of all confirmed or probable etiologic agents. Herpes simplex virus (HSV) and enteroviruses accounted 11% each, and influenza A virus 7%. VZV seems to have achieved a major role in viral infections of CNS. In encephalitis in our population, VZV is clearly more commonly associated with these neurological diseases than HSV. The increase in VZV findings may in part be a pseudophenomenon due to improved diagnostic methods, however, a true increase may have occurred and the pathogenetic mechanisms behind this should be elucidated.     

Availability, content and quality of local guidelines for the assessment of suicide attempters in university and general hospitals in the Netherlands

OBJECTIVE: This study was performed to investigate the availability, content and quality of local guidelines for the assessment of suicide attempters in the Netherlands. METHOD: All university and general hospitals in the Netherlands were asked to provide their local guidelines. Published national guidelines and the Appraisal of Guidelines for Research and Education (AGREE) instrument were used to evaluate the content and quality of the local guidelines. RESULTS: Eighty-eight hospitals (90.7%) responded; 34 (38.6%) reported that they used local guidelines. Twenty-seven guidelines were submitted for evaluation. Most of the guidelines were more than 5 years old and had not been updated recently. The contents of the guidelines differed. Criteria addressing patient safety, staff attitude toward patients, reassessment of nonalert patients, relevant stressors, involvement of significant others and aftercare were found in less than 50% of the guidelines. Although psychiatric consultation was incorporated in almost 80%, the psychiatrist's tasks were specified infrequently. The guidelines seldom required monitoring of staff compliance. Only in the AGREE domain "clarity and presentation" was the mean score above 60% of the maximum. According to the instructions for the AGREE instrument, 10 (37.0%) of the 27 guidelines were recommended (with provisos or alterations) and 1 was strongly recommended for use in practice. CONCLUSIONS: In the Netherlands, a minority of hospitals reported use of local guidelines for the assessment of suicide attempters. When available, the guidelines were mostly not based on international standards, their contents varied greatly and their quality was unsatisfactory.     

Specific in vitro IgG subclass synthesis and lymphocyte proliferation responses in herpes virus encephalitis

Cerebrospinal fluid, peripheral blood lymphocytes (PBL) and sera from 5 patients with herpes simplex encephalitis (HSVE), 3 with varicellae zoster (VZV) meningoencephalitis and 5 with encephalitis of unknown origin (NUD) were analyzed. Lymphocytes from both blood and CSF were shown to synthesize anti-VZV IgG subclasses in VZV meningoencephalitis and anti-HSV IgG subclasses in HSVE. The subclass patterns of CSF and in vitro synthesized anti-viral IgG were similar, suggesting that a considerable portion of the antiviral IgG subclasses detected are synthesized in the CNS compartment. Antigen presentation in vitro seemed to produce a heterologous IgG4 and/or 3 response in 3 patients. Lymphocyte proliferation was detectable in response to HSV and VZV, respectively.