医用几丁糖在关节腔注射应用的专家共识(2018版)

正一、共识背景关节腔注射作为关节相关疾病治疗措施中的一类干预手段,近年来已成为临床研究与指南制定讨论的热点之一。现有用于关节腔内注射的药物或生物制剂产品包括:透明质酸、糖皮质激素、富血小板血浆、几丁糖、间充质干细胞等。近年来,医用几丁糖关节腔注射作为一种关节内粘弹性物质补充在我国被应用于外科手术后预防粘连、软骨保护及骨关节炎治疗等临床实践中,并有学者报告了通过关节     

外周动脉疾病抗栓药物治疗——2017欧洲外周动脉疾病诊治指南解读

欧洲心脏病学会(ESC)与欧洲血管外科学会于2017年发布了新版的《ESC外周动脉疾病诊治指南》。与2011版指南相比,更新了14条推荐建议,新增了16条推荐建议。其中对于外周动脉疾病的抗栓治疗,亦给出了详细的推荐意见以及循证医学证据。本文根据指南更新的循证医学证据,结合临床实际问题,重点对指南给出外周动脉疾病抗栓药物治疗推荐意见进行解读,以期医务工作者能更好的理解和遵循指南。     

水飞蓟制剂肝病临床应用专家共识

随着水飞蓟制剂循证医学证据的积累,水飞蓟制剂已被多部肝病诊疗指南列为抗炎保肝治疗药物。但限于篇幅,上述指南均未就水飞蓟制剂的具体临床应用展开论述,也未能给出详尽的循证医学证据。为此,我们根据临床水飞蓟制剂在各种肝病临床应用的结果作为循证医学的证据,参照肝病治疗、诊疗各项指南和共识,结合肝病治疗的发展趋势,讨论并撰写本专家共识,以期为临床医生进一步提供更为可靠的用药依据。     

透明质酸钠治疗膝骨性关节炎的疗效分析

目的观察透明质酸钠关节腔内注射治疗膝骨性关节炎(OA)的临床效果。方法256例OA患者随机分成治疗组与对照组,治疗组应用透明质酸钠,对照组应用复方倍他米松,行膝关节腔注射,治疗前、后观察临床症状改善情况。结果两种药物均可有效缓解OA的临床症状。结论应用透明质酸钠治疗OA疗效明显,无严重不良反应。     

《SVS/AVF/AVLS下肢静脉曲张管理临床实践指南2023年版》更新要点解读

美国血管外科学会、美国静脉论坛和美国静脉与淋巴学会最近发布了2023年版下肢静脉曲张临床实践指南,并就影响下肢静脉曲张（CEAP 2类疾病）患者管理的关键问题提供了新的循证建议。指南的主要内容包括对下肢静脉曲张患者的临床评估、加压治疗、药物和营养补充剂、浅静脉主干反流腔内消融术与高位结扎-剥脱术、属支静脉曲张和穿静脉功能不全的评估和治疗、血栓并发症的管理以及静脉曲张出血和浅静脉瘤的管理及其治疗提出了循证建议。本文总结新版指南更新要点,并结合最新循证医学进展进行解读,旨在为国内同行的临床实践提供参考。     

在全球循证医学领域创建诊疗指南

背景与目的在医学文献数量呈指数增长的年代,为确保我们提供给患者的医疗保健服务的证据是有效和科学的数据,医师和卫生政策制定者需要依据结构合理、以证据为基础的诊疗指南。然而,诊疗指南的创建过程与公认的研究计划又有不同之处。方法本文将详细阐述创建循证诊疗指南的步骤。结果创建循证诊疗指南的7个基本步骤包括：①确定主题;②选择工作组;③文献回顾;④编写指南;⑤同行评议;⑥制定文献回顾和修订计划;⑦传播。结论考虑到诊疗指南对于医师日常诊疗实践的重要性,本文为诊疗指南（循证医学的重要组成部分）的创建提供了一个实用向导。     

关节镜下清理联合富血小板血浆注射治疗Kellgren-Lawrence分级Ⅰ-Ⅲ级膝骨关节炎

目的:探讨关节镜下清理联合关节腔内注射富血小板血浆(platelet-rich plasma,PRP)治疗Kellgren-Lawrence分级(K-L)Ⅰ-Ⅲ级膝骨关节炎(knee osteoarthritis,KOA)的临床疗效.方法:回顾性分析2015年11月至2019年1月行关节镜下清理联合关节腔内注射药物治疗...     

从循证医学到精准医学的思考

20世纪临床医学最大的进步,是从以个人经验及直觉为基础的传统个性化治疗,进化到基于基础及临床研究数据的循证医学,如同一场革命,短时间内,改变了临床医师的思维方法与实践模式。但是,基于对疾病模糊的诊断、分期、评估而实施的临床研究,常常产生模糊的结论,远离临床实际,甚至起到误导作用。许多疾病治疗指南的"半衰期"仅有10年。学者们试图以"改良"来弥补当今循证医学的先天不足,但效果甚微。因此,21世纪的今天,临床医学需要另一次理念的革命,超越循证医学,从分子生物学本质思考疾病,依据驱动因子将疾病重新分类,实现对疾病精准的诊断、分期、评估,以达到精准的预防及治疗,从而迈向精准医学的时代。     

不同部位注射复合药物对前交叉韧带重建术后疼痛的影响

目的 比较不同部位注射复合镇痛药物对前交叉韧带重建术后疼痛的影响.方法 100例行前交叉韧带重建手术的患者,随机分为四组,每组25例.分别于关节腔内、关节腔周围滑膜组织、大腿根部股神经周围注射复合镇痛药物以及对照组（不注射任何药物）.比较术后6、12、24、48 h的疼痛差异.结果 三个复合镇痛药物注射组镇痛作用均明显优于对照组（P〈0.01）,股神经阻滞镇痛效果明显优于关节腔内注射和关节腔周围注射（P〈0.01）,关节腔内注射与关节腔周围注射镇痛效果差异无统计学意义（P〉0.05）.结论 不同部位注射复合药物可产生程度不同镇痛作用,以股神经阻滞镇痛效果最好.     

膝骨关节炎的临床实践指南

美国骨科医师学会（AAOS）近期发布了有关“治疗膝骨关节炎”的循证临床实践指南。指南建议,如果病人只有骨关节炎的症状而没有膝关节内游离体或半月板撕裂等其它问题,则不提倡进行关节镜灌洗。如果存在上述机械性损伤。关节镜检查和治疗有潜在的益处。目前的证据显示,单纯行关节灌洗并不能减轻病人骨关节炎的症状．反而使患者承担额外的风险。指南强调了减重对延缓骨关节炎疾病进展的重要意义：对超重病人而言,如体重质量指数（BMI）〉25,则应至少减重5％：同时鼓励病人进行低强度有氧锻炼。工作组建议,如无药物禁忌症,有症状的膝骨关节炎患者可接受以下镇痛疗法：醋氨酚（不超过4g／d）;非甾体抗炎药（NSAIDs）：关节内注射皮质类固醇药物。此外,现在的证据尚不允许工作组推荐使用的疗法有：支撑疗法、针刺以及关节腔内注射透明质酸。     

Treatment of adhesive capsulitis with intra-articular hyaluronate: A systematic review

Sodium hyaluronate injection into the glenohumeral joint is a treatment option in the management of adhesive capsulitis of the shoulder. We hypothesized that a systematic review would demonstrate that intra-articular sodium hyaluronate injections would result in significant improvements in passive range-of-motion, shoulder and general clinical outcome measures, and pain scales at short- and mid-term follow-up. Multiple medical databases were searched for levels I-IV evidence with a priori defined specific inclusion and exclusion study criteria. Clinical outcome measures used included Constant score, VAS pain scores, Cho functional scores, JOA scores, and range-of-motion measurements. Seven studies were included (four Level I and three Level IV; 292 subjects, 297 shoulders). Mean subject age was 59.1 years and mean pre-treatment duration of symptoms was 7.3 months. 140 subjects underwent one or multiple hyaluronate injections (120 glenohumeral joint; 20 subacromial bursa). Clinical follow-up was mean 9.0 weeks. Sodium hyaluronate injection into the glenohumeral joint has significantly improved shoulder range-of-motion, constant scores, and pain at short-term follow-up following treatment of adhesive capsulitis. Isolated intra-articular hyaluronate injection has significantly better constant scores than control. Isolated intra-articular hyaluronate injection has equivalent clinical outcomes and range-of-motion compared to intra-articular corticosteroid injection. Intra-articular hyaluronate injection was safe, with no reported complications within the studies in this review. Sodium hyaluronate injection into the glenohumeral joint is a safe, effective treatment in the management of adhesive capsulitis of the shoulder. Short-term evidence indicates that clinical outcomes are better than control and equivalent to intra-articular corticosteroid injection.     

A comparison of Australian and European evidence-based guidelines for intervention in acute,non-specific low back pain

This review provides an overview of evidence-based clinical practice guidelines for acute non-specific low back pain, first introduced in 1994. Since then 11 countries world-wide have produced similar guidelines, which are broadly consistent in their findings. The most recent guidelines were produced in Australia, as part of a wider evidence-based review of acute musculoskeletal pain.Evidence-based clinical practice guidelines are a synthesis of the evidence available at the time of publication, and are employed as a method of aligning different treatment provider groups, including osteopaths, whilst encouraging the adoption of evidence-based ‘best clinical practice’.This review provides an overview of evidence-based intervention in acute, non-specific low back pain from the Australian and European guidelines. The review also provides the reader with an insight into how the evidence was categorised in both jurisdictions, and highlights any discrepancies.     

How to alter surgical practice? The use of guidelines to encourage day-case haemorrhoidectomy

BACKGROUND: Day case haemorrhoidectomy has been shown to be safe and acceptable to patients. The best way to introduce such evidence into clinical practice remains unclear: The aim is to assess the effectiveness of guidelines on the introduction of day-case haemorrhoidectomy in a general surgical unit. METHODS: Prospective audit of day-case haemorrhoidectomy and retrospective review of in-patient procedures. The effectiveness of guidelines in encouraging day-case haemorrhoidectomy is assessed by analysis of avoidable admissions. RESULTS: In the year prior to introduction of the guidelines 75 patients had elective haemorrhoidectomy, none as day-cases. In the year following the introduction of the guidelines 80 patients had elective haemorrhoidectomy, 35 (44%) as day cases. There were no complications or re-admissions. Of the 45 in-patients 31 (69%) were eligible for day surgery. CONCLUSIONS: The establishment of clear guidelines and their dissemination results in significant changes in practice. However, audit has demonstrated that alternative strategies are needed to encourage changes in clinical practice.     

Vascular Access Surveillance: Time to End the Controversy

The establishment and maintenance of permanent vascular access for hemodialysis patients are important clinical problems. Vascular access surveillance, currently mandated by the CMS, refers to the task of identifying and correcting an underlying vascular access stenosis to prolong vascular access patency and survival. While this premise makes intuitive sense, this article discusses the underlying evidence to support it, outlining disparate conclusions of clinical practice guidelines and a recent commentary by experts in vascular access.     

Platelet-rich plasma injections for knee pathologies: a review

Platelet-rich plasma (PRP) has found applications in various pathological conditions of the knee as in other areas. There are various preparations in the PRP family, and these have different terminologies. This paper reviews PRP injections in knee conditions in human clinical studies. We have divided PRP application for knee pathologies into extra-articular, intra-articular and intra-operative. There is level III evidence for PRP use in cases of patellar tendinopathy as well as in arthritis. These injections provide better results in degenerative chondropathy and early stages of arthritis than in cases of established osteoarthritis. In cases of ACL reconstruction using autograft, there are level I studies that demonstrate faster graft maturation with intra-operative use of PRP. Evidence for use in muscle and ligament injuries, as well as intra-operative use for cartilage defect re-attachment, is limited to few case reports. There is less evidence proving the benefits of PRP product use in the knee as compared to other areas in the body. Importantly, at the same time, there are no adverse effects following use of these products. Various preparations may be used as per individual and institution preference and guidelines regarding their applications are available. Further data is needed to establish the efficacy of these over other available injection treatments in knee pathologies.     

Guideline of guidelines: follow-up after orchidectomy for clinical stage 1 testicular cancer

Several medical organisations have developed evidence-based guidelines for the diagnosis, management, and follow-up of testicular cancer. This article aimed to review, compare, and summarise the most updated international guidelines and surveillance protocols for clinical stage 1 (CS1) testicular cancer. We reviewed a total of 46 articles on proposed follow-up strategies for testicular cancer, and six clinical practice guidelines including four guidelines published by urological scientific associations and two guidelines published by medical oncology associations. Most of these guidelines have been developed by panels of experts with different backgrounds in clinical training, and geographic practise patterns, which explains the considerable variability between published schedules, and recommended follow-up intensity. We present you with a comprehensive review of the most important clinical practice guidelines and propose unifying recommendations based on the most up to date evidence to help standardise follow-up schedules based on patterns and risk of disease relapse.     

Translation of benign prostatic hyperplasia guidelines into clinical practice

PURPOSE OF REVIEW: The aim of this article is to describe the current position of clinical practice guidelines for benign prostatic hyperplasia in daily management and identify the potential barriers that may hinder the implementation of guidelines into clinical practice. RECENT FINDINGS: Recent studies have attempted to compare and grade benign prostatic hyperplasia clinical practice guidelines using appraisal instruments underlining the issues of quality and updates of guidelines. Surveys have evaluated the adoption of guidelines from the urological community and recent studies have made major contributions to our knowledge of the translation of evidence to daily practice. SUMMARY: Numerous clinical practice guidelines (both national and international) for benign prostatic hyperplasia exist. High methodological quality clinical practice guidelines are likely to be the most beneficial to patients and strength of recommendations depends on available evidence. Efforts to implement guidelines are not always successful and a considerable variation especially in diagnostic assessment of benign prostatic hyperplasia has been reported. Difficulties in translation of benign prostatic hyperplasia guidelines into clinical practice are related to lack of knowledge but also to differences in routine practices, beliefs, cost, availability, and reimbursement policy. Bridging the implementation gap represents a challenging task for clinical practice guideline supporters.     

Utilization of incontinence clinical practice guidelines.

Clinical practice guidelines (CPGs) are evidence-based recommendations for best practice and have been developed with the assumption they will be embraced by practitioners; a further assumption is that clinical practice guidelines will improve the delivery of care. In this article, we provide a working definition of evidence-based practice, discuss the strengths and limitations of CPGs, describe the implementation of CPGs in the context of urinary incontinence, and consider the steps that the WOCN has taken to initiate evidence-based practice. Current issues are presented along with initiatives that have resulted in clinical practice guidelines on incontinence from the United States, United Kingdom, and Canada. On the basis of the current literature, it is concluded that clinical practice guidelines can play an important role in WOCN practice and that the implementation of guidelines may improve clinical practice. However, guidelines are only as valid as the evidence on which they are based and may not take into account gender or cultural differences or the effect that comorbid conditions can have on treatment outcomes. Finally, guidelines must follow a comprehensive approach that involves management and staff and includes education, facilitation, evaluation, feedback, and an understanding of change strategies.     

Is Anesthetic Hip Joint Injection Useful in Diagnosing Hip Osteoarthritis? A Meta-Analysis of Case Series

To assess the diagnostic value of intra-articular anesthetic hip injection in patients with hip pain atypical for osteoarthritis (OA), literature was searched. Included were studies assessing the diagnostic value of anesthetic hip injections in differentiating between pain caused by OA or another source. Pooled estimates of sensitivity and specificity with 95% confidence intervals (CI) were calculated. Of the 1387 potentially eligible articles, nine case series with high risk of bias could be included. The pooled sensitivity was 0.97 (95% CI 0.87, 0.99). Specificity was 0.91 (95% CI 0.83, 0.95). For clinical practice, no recommendation can be made regarding the use of hip injections for diagnosing hip OA. High quality, accurately reported studies are needed to provide better evidence on the diagnostic role of hip injection.