经典中医古方治疗骨质疏松症的系统评价*

背景：经典中医古方在针对骨质疏松症的治疗中有着较好的疗效,但以系统科学方法进行Meta分析以明确其总体疗效的报道不多。 目的：系统评价中医经典古方在治疗骨质疏松症的疗效性和安全性,为经典古方在骨质疏松症中的应用提供依据。 方法：计算机检索中国期刊全文数据库(2001/2010)、中国重要会议论文全文数据库(2001/2010)、维普数据库(2001/2010)等国内各大数据库,手工检索所有纳入文献的参考文献。纳入经典中医古方治疗骨质疏松症的随机对照试验(RCT)。评价纳入研究的方法学质量并进行资料提取后,采用RevMan4.2软件进行Meta分析。 结果与结论：共纳入包括1 235例受试者在内的随机对照试验17个,Jadad评分4个2分,其余均为1分,且所有研究均处于C级,质量不高。经典古方与单纯西药治疗相比,总体疗效合并OR=3.82, 95%CI[2.70~5.41];症状积分WMD=-1.95,95%CI[-2.19~1.72];腰椎骨密度WMD=0.04,95%CI[0.03~0.06],其他部分骨密度WMD=0.04,95%CI[0.03~0.06]。经典古方加西药对比西药,总有效率OR=3.09,95%CI[1.58~6.07]。提示现有临床研究证据表明中医经典古方在治疗骨质疏松症方面存在一定的优势,未见明显不良反应的报道。     

心理治疗对阈下抑郁疗效的Meta分析

目的 系统评价心理治疗对阈下抑郁的疗效。方法 检索 PubMed、PsycINFO、Embase、 Cochrane Library、中国知网数据库（CNKI）、万方数据库，文献检索时间均为建库至 2020 年 4 月，纳入心 理治疗对阈下抑郁疗效的随机对照试验。结果 27 个随机对照试验共 5 503 例阈下抑郁患者符合纳入 标准。Meta 分析结果显示，心理治疗对阈下抑郁的疗效与对照组比较差异有统计学意义［SMD=-0.38， 95%CI：（-0.48～-0.28）］。亚组分析结果显示，面谈心理治疗与网络心理治疗对阈下抑郁的疗效与对照 组比较差异有统计学意义［SMD=-0.41，95%CI：（-0.52～-0.30）；SMD=-0.40，95%CI：（-0.67～-0.13）］。 分级治疗对阈下抑郁的疗效与对照组比较差异无统计学意义［SMD=-0.12，95%CI：（-0.27～0.04）］， 认知行为治疗与行为激活对阈下抑郁的疗效与对照组比较差异有统计学意义［SMD=-0.41，95%CI： （-0.54～-0.28）；SMD=-0.44，95%CI：（-0.76～-0.12）］。结论 心理治疗对阈下抑郁有疗效，但结果需要 更多的非认知行为治疗与大样本试验加以验证。     

黄连素对精神分裂症患者血脂水平影响的Meta分析

目的系统评价黄连素对精神分裂症患者血脂水平的影响,为精神分裂症患者血脂干预方案的选择提供参考。方法系统检索英文数据库(PubMed、PsycINFO、Embase、Cochrane Library)和中文数据库(中国期刊全文数据库、万方数据库),纳入关于黄连素对精神分裂症患者血脂水平影响的随机对照研究(RCT)。由两位研究者独立进行文献筛选、数据提取和方法学质量评价,采用RevMan 5.3进行Meta分析。结果共纳入3篇RCT,包括207例精神分裂症患者,其中黄连素组103例,对照组104例。Meta分析结果显示,黄连素组的甘油三脂水平低于对照组(WMD=-0.54,95%CI:-0.75～-0.33),差异有统计学意义(P0.01);黄连素组胆固醇水平低于对照组(WMD=-0.48,95%CI:-0.67～-0.29),差异有统计学意义(P0.01);黄连素组低密度脂蛋白胆固醇水平低于对照组(WMD=-0.56,95%CI:-0.74～-0.38),差异有统计学意义(P0.01);黄连素组高密度脂蛋白胆固醇水平高于对照组(WMD=0.06,95%CI:0.02～0.10),差异有统计学意义(P0.01)。结论黄连素联合抗精神病药物可改善精神分裂症患者的血脂水平,调控脂肪代谢。     

艾司西酞普兰与帕罗西汀治疗老年抑郁症患者疗效与安全性比较的Meta分析

目的 系统评价艾司西酞普兰对比帕罗西汀治疗老年抑郁患者的疗效与安全性，为临床 治疗老年抑郁症患者的药物选择提供循证参考。方法 通过计算机检索中国期刊全文数据库（CNKI）、 万方数据库、中国生物医学文献数据库（CBM）、维普中文科技期刊数据库（VIP）、PubMed 及The Cochrane Library，收集艾司西酞普兰（试验组）对比帕罗西汀（对照组）治疗老年抑郁患者的随机对照试验（RCT）， 对符合纳入标准的研究进行资料提取和质量评价后，采用Rev Man5.3统计软件进行Meta分析。结局指 标包括汉密尔顿抑郁量表（HAMD）评分、老年抑郁量表（GDS）评分、痊愈率、显效率、不良反应（口干、头 晕、头疼、恶心、食欲不振、疲倦、嗜睡、心动过速、便秘）发生率。结果 共纳入10项RCT，共计823例患 者。Meta分析结果显示，试验组患者痊愈率（OR=1.83，95%CI：1.26～2.65）、HAMD评分（OR=-2.80，95%CI： -3.50～-2.11）、GDS评分（OR=-2.03，95%CI：-3.12～-0.93）、总不良反应发生率（OR=0.45，95%CI：0.36～0.58）、 口干发生率（OR=0.32，95%CI：0.15～0.69，）、头晕发生率（OR=0.38，95%CI：0.17～0.86）、食欲不振发生 率（OR=0.35，95%CI：0.16～0.79）、恶心发生率（OR=0.40，95%CI：0.24～0.69）、头疼发生率（OR=0.36，95% CI：0.14～0.95）、疲倦发生率（OR=0.39，95% CI：0.19～0.80）、便秘发生率（OR=0.34，95% CI：0.17～0.69）均 显著低于对照组，差异均有统计学意义（均P＜0.05）。试验组患者显效率（OR=0.91，95% CI：0.63～1.31， P=0.62）、嗜睡发生率（OR=0.57，95% CI：0.22～1.50， P=0.26）、心动过速发生率（OR=0.38，95% CI：0.14～1.02， P=0.05）与对照组比较，差异均无统计学意义。结论 现有证据表明，艾司西酞普兰对比帕罗西汀治疗 老年抑郁症患者，在疗效与安全性方面均具有一定优势。     

上臂电子血压计与水银血压计测量一致性的Meta分析

目的评价电子血压计与水银血压计测量血压值的一致性。方法计算机检索及手工辅助检索1952—2015年在中文医学期刊和外文医学期刊已公开发表的有关上臂电子血压计与水银血压计检测血压值一致性的文献,将符合文献纳入标准的研究进行质量评价,使用Review Manager 5.1进行Meta分析。结果符合纳入标准的随机对照试验文献12篇,上臂电子血压计与水银血压计测量具有一致性。收缩压WMD=1.26,95%CI=-0.47~2.98(P0.01);舒张压WMD=-0.47,95%CI=-0.97~0.03,P0.01。结论上臂电子血压计可以替代水银血压计。本Meta分析期待能有更多的有价值的、高质量的临床随机对照试验予以验证。     

术前辅助栓塞联合手术治疗脑膜瘤的Meta分析

目的使用Meta分析方法评价术前栓塞联合手术治疗脑膜瘤的临床疗效及安全性。方法计算机检索medline、sciencedirect、springer、中国期刊全文数据库、中国生物医学文献数据库、中文科技期刊全文数据库,并辅手工和其他检索,纳入国内外比较术前辅助栓塞联合手术治疗与单纯手术治疗脑膜瘤的随机或非随机对照试验,由2名评价员独立选择文献、提取资料并交叉核对,并对其方法学质量进行评价,采用RevM an 5.2软件进行统计分析。结果总计有12篇文献纳入Meta分析(725例患者)。Meta分析结果显示脑膜瘤术前辅助栓塞联合手术组和单纯手术组在全切率、出血量、输血量、术后恢复时间方面,差异有统计学意义[OR=4.08,95%CI(2.45,6.77);WMD=-203.50,95%CI(-251.53,-155.47;WMD=-282.41,95%CI(-372.71,-192.10),P0.00001;WMD=-4.38,95%CI(-5.69,-3.07),P0.00001],但在手术时间方面无统计学意义[WMD=-0.39,95%CI(-1.72,0.94),P=0.56]。虽然漏斗图形右侧底部出现缺失,但Begg法及Egger法检测均提示研究中不存在明显的偏倚。结论证明了脑膜瘤的术前栓塞有利于提高肿瘤的全切率,减少术中出血、输血,并且缩短恢复时间。     

纳洛酮治疗急性重症颅脑损伤的Meta分析

目的系统评价纳洛酮治疗急性重症颅脑损伤(sTBI)的临床疗效及安全性。方法通过计算机检索中国生物医学文献数据库(CBM)、维普(VIP)、中国期刊网全文数据库(CNKI)、万方数据库等。纳入纳洛酮对比安慰剂治疗急性重症颅脑损伤的随机对照试验(RCT)进行Meta分析。结果共纳入19个RCT,共2 332例患者。Meta分析结果显示:①早期疗效方面,纳洛酮组对比安慰剂组具有统计学意义:心率异常发生率优势比(OR)为0.30,0.21,0.43,95%可信区间(95%CL);P0.00001,血压异常发生率[OR=0.25,0.17,0.36,95%CI;P0.00001],高颅压控制率[OR=0.35,0.23,0.54,95%CI;P0.00001];②中期疗效:两组患者GCS评分、GOS评分具有显著统计学意义:治疗后10 d GCS评分[OR=1.76,1.55,1.97,95%CI;P0.00001],语言、运动障碍发生率[OR=0.65,0.43,0.98,95%CI;P=0.04],重残率[OR=0.47,0.30,0.73,95%CI;P=0.0001];③随访死亡率:纳洛酮组明显低于安慰剂组,两组间差异具有显著统计学意义[OR=0.51,0.38,0.67,95%CI;P0.00001]。结论国内现有的临床随机对照试验研究结果显示,纳洛酮在早期能有效降低呼吸异常、血压异常的发生率,还能有效控制颅内高压症状,在远期可显著改善患者GOS评分、降低死亡率。纳洛酮具有较高的临床实用性和安全性。     

阿加曲班治疗急性缺血性卒中的系统评价

目的系统评价阿加曲班治疗急性缺血性卒中的疗效和安全性。方法通过计算机检索、人手检索及向药厂索取资料等方法,全面收集有关阿加曲班治疗急性缺血性卒中的随机对照试验(randomized controlled tri-al,RCT)和半随机对照试验(Quasi-randomized control trial),由两名评价员按纳入标准,进行各自独立检索和筛选文献,并进行资料提取。按Cochrane协作网系统评价的方法进行评价。在严格进行文献质量评价的基础上,使用RevMan5.0软件进行Meta分析。结果最终有10个随机对照试验,1个半随机对照试验复核标准并被录用进行系统分析,它们包括1542例患者,Meta分析显示,阿加曲班治疗组神经功能改善优于安慰剂组[OR2.40,95%CI(1.65,3.49),P<0.00001],神经功能改善优于奥扎格雷组[OR2.01,95%CI(1.02,3.97),P=0.04],神经功能改善优于阿司匹林组[OR2.70,95%CI(1.50,4.85),P=0.0009]。只有2个研究发现有颅内出血病例,进一步对这两个研究进行Meta分析发现,治疗组和对照组比较无统计学显著性差...     

甜梦口服液治疗抗精神病药物所致女性精神分裂症患者高泌乳素血症效果和安全性的Meta分析

目的 系统评价甜梦口服液治疗抗精神病药物所致女性精神分裂症患者高泌乳素血症的效果和安全性,为抗精神病药物所致高泌乳素血症的干预提供参考。方法 计算机检索英文数据库（PubMed、Cochrane Library、PsycINFO和Embase）和中文数据库（中国知网和万方数据库）,检索时限为建库至2022年9月16日,纳入关于甜梦口服液治疗抗精神病药物所致女性精神分裂症患者高泌乳素血症随机对照试验的文献。由3位研究者根据PICOS原则独立筛选文献并提取数据,对纳入文献的方法学进行质量评价,采用RevMan 5.3进行Meta分析。结果 共纳入3篇文献,包括256例伴有高泌乳素血症的女性精神分裂症患者,其中干预组和对照组各128例。Meta分析结果显示,在治疗终点时,干预组高泌乳素血症的改善效果优于对照组（RR=1.73,95%CI:1.07～2.79,P＜0.05）,干预组血清泌乳素水平低于对照组（WMD=-55.17,95%CI:-68.16～-42.18,P＜0.01）,干预组阳性和阴性症状量表（PANSS）总评分低于对照组（WMD=-7.36,95%CI:-8.94～-5.77,...     

团体认知行为疗法治疗失眠障碍疗效的Meta分析

目的 系统评价团体认知行为疗法（GCBT）治疗失眠患者的临床疗效及其后期效应。 方法 检索EMbase、Cochrane Library、Medline、中国知网和万方数据库，查找符合纳入标准的随机对照 研究，GCBT组患者接受团体认知行为治疗，内容主要包括睡眠卫生宣教、认知治疗、放松训练、睡眠限 制和刺激控制；对照组患者接受安慰剂治疗、健康生活教育、常规护理、等待治疗等。提取睡眠日记中 入睡潜伏期、入睡后觉醒时间、总睡眠时间和睡眠效率，以及睡眠严重程度指数和匹兹堡睡眠质量指数 问卷，并采用RevMan5.3和STATA15.1软件进行Meta分析。结果 最终纳入11篇文献，共计814 例患者， 其中 GCBT 组441 例，对照组373 例。Meta 分析结果显示：GCBT 组入睡潜伏期（WMD=-15.06，95%CI： -19.06～-11.05，P＜ 0.05）、入睡后觉醒时间（WMD=-34.95，95%CI：-49.96～-19.93，P ＜ 0.05）、失眠 严重程度指数（WMD=-6.13，95%CI：-8.04～-4.22，P＜ 0.05）、匹兹堡睡眠质量指数评分（WMD=-2.49， 95%CI：-4.11～-0.87，P＜ 0.05）均低于对照组，睡眠效率高于对照组（WMD=10.46， 95%CI：6.89～14.03， P＜ 0.05），两组总睡眠时间差异无统计学意义（P＞ 0.05）。早期随访时，GCBT组入睡后觉醒时间 （WMD=-32.51，95%CI：-58.61～ -6.41，P ＜ 0.01）、失眠严重程度指数（WMD=-6.01，95%CI：-8.40～ -3.62，P＜ 0.05）、匹兹堡睡眠质量指数评分（WMD=-4.33，95%CI：-7.06～-1.59，P＜ 0.05）均低于对照 组（均P＜ 0.05），总睡眠时间（WMD=0.32，95%CI：0.10～0.54，P＜ 0.05）、睡眠效率（WMD=10.51， 95%CI： 5.99～15.02，P＜ 0.05）均高于对照组（均P＜ 0.05），两组入睡潜伏期差异无统计学意义（均P＞ 0.05）。长 期随访时，GCBT 组睡眠效率高于对照组（WMD=5.30，95%CI：1.61～8.98，P＜ 0.05），匹兹堡睡眠质量指 数评分低于对照组（WMD=-2.80，95%CI：-3.82～-1.78，P＜ 0.05），两组的入睡潜伏期、入睡后觉醒时间 及总睡眠时间差异均无统计学意义（均P ＞ 0.05）。结论 GCBT对失眠障碍患者的临床疗效可靠，且在 后期随访中仍持续有效，但其疗效会随着时间推移而下降。     

Treatment Considerations in Anticonvulsant Monotherapy

Summary: The long-standing practice of polypharmacy in treating epilepsy is giving way to use of monotherapy. Monotherapy can improve seizure control as well as reduce the risk of serious idiosyncratic reactions, dose-related side effects, and complex drug interactions. Monotherapy also offers improved compliance and cost-effectiveness. The basis of monotherapy is accurate diagnosis and assessment of the patient's seizure type(s), followed by selection of a single appropriate anticonvulsant drug. Many patients currently treated with multiple anticonvulsants can be successfully converted to monotherapy with a carefully monitored program in which troublesome and redundant drugs are gradually withdrawn from the therapeutic regimen.     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

Dextromethorphan: Cellular Effects Reducing Neuronal Hyperactivity

Summary: Dextromethorphan is a dextrorotary morphinan without affinity for opioid receptors, commonly used as an antitussive medication. During the past 5 years, interest in the compound and its demethylated derivative, dextrorphan, has been revived because additional neuroprotective and an-tiepileptic properties were found in in vitro studies, animal experiments, and a few clinical cases. Both morphinans are able to inhibit N -methyl-D-aspartate (NMDA) receptor channels and voltage-operated calcium and sodium channels with different potencies. The inhibition of the NMDA receptor is believed to be the predominant mechanism of action responsible for the anticonvulsant and neuroprotective properties of the compounds.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

Pediatric Epilepsy Surgery

Summary: The use of implantable arrays of epidural electrodes has made it possible to carry out extraoperative electrocorticography (ECoG) and functional localization in the awake child. This has permitted cortical excisions that are determined by criteria similar to those obtained during surgical procedures performed under local anesthesia in adults. In addition, the method also permits simultaneous ECoG and video monitoring during the child's symptomatic seizures, providing additional important localizing information that is impractical to obtain in operations under local anesthesia. We report our experience with 75 children, ages 5 months to 15 years, whom we have managed with epidural electrode arrays. The method of extraoperative ECoG is described and illustrative cases are presented to demonstrate its feasibility and utility in children. In addition, we call attention to gliomas as a common cause of chronic focal seizures in children. Of 49 children undergoing resection and followed for from 1 to 14 years (mean of 5.8 years), 32 (65%) are either seizure free or have had a significant reduction in seizure frequency that has unambiguously improved their quality of life. The results are analyzed further by relating the surgical outcome to each of the pathologic entities that caused the seizures. This analysis reveals the variety of neurological conditions that commonly cause intractable focal seizure disorder in children and distinguishes those pathologic entities in which the seizure disorder is apt to respond to surgical intervention from those that will not.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

Anticonvulsant Drugs and Cognitive Function: A Review of the Literature

Summary: Alterations of cognitive function are separate from disturbances of behavior seen in association with epilepsy. The nature of the cognitive disability may to a certain extent depend on the seizure type. Partial seizures, mainly derived from a temporal lobe focus, impair memory tasks, while generalized seizures seem to have more effect on attentional abilities. A number of studies, reviewed in this paper, suggest that anticonvulsant drugs further impair cognitive function. Maximal impairments are seen in patients receiving polytherapy: rationalization of polytherapy improves cognitive abilities. Studies in children and adults have allowed differentiation of the effects of various commonly used antiepileptic agents. Maximal cognitive deficits are seen with. phenytoin, while phenobarbital and sodium valproate induce moderate disturbances, and carbamazepine seems relatively free from such toxicity. Further research is needed on the interrelationship between types of seizure disorders, types of anticonvulsant medications, and cognitive function.