一例不明原因消化道出血患者的循证治疗

目的针对1例不明原因消化道出血患者,检索当前最佳证据,探讨临床上常见问题,并为患者制定合理的治疗方案,以控制患者症状,降低病死率。方法在充分评估患者的情况后,提出临床问题,从Cochrane图书馆、MEDLINE、EMbase(1990～2010)、SCIE和CNKI中检索有关不明原因消化道出血的诊疗及临床常见问题的随机对照试验和系统评价,检索时间从建库至2010年,对所获证据进行评价,并结合患者和家属意愿制定治疗方案。结果共检索出与不同问题相关的随机对照试验30篇,系统评价/Meta分析5篇。分析证据并结合患者意愿,最终为患者制定了合理的检查和治疗方案。该患者在胶囊内镜中发现小肠Mickel憩室,在外科行腹腔镜下憩室局部切除。通过6个月的随访,证实该方案对患者有满意的疗效。结论采用循证治疗方法,为不明原因消化道出血患者制定合理治疗方案,可有效提高患者治疗效果。     

伴尿微量白蛋白增高的2型糖尿病肾病患者的循证治疗（附2例报告）

目的 为两例尿微量白蛋白增高的2型糖尿病肾病患者制定治疗方案。方法 根据循证临床实践的方法，提出问题，检索证据，对所获证据进行评价，并结合患者意愿为患者制定治疗方案。结果 共纳入14个随机对照试验，2个系统评价，2个Meta分析和41个临床指南。证据结果表明：①尿白蛋白增高是糖尿病患者心血管事件的独立危险因素；②血管紧张素受体拮抗剂能降低2型糖尿病肾病患者尿白蛋白水平。③降糖降压治疗能使此类患者获益。结合患者情况，应用证据治疗1月后，2例患者血肌酐恢复正常，尿白蛋白转阴性。结论 以高质量证据，结合患者情况制定治疗方案，能明显保护肾脏及心脏，降低尿白蛋白，但远期预后尚需要更长时间的随访观察。     

糖尿病患者急性卒中后血糖监测及管理的最佳证据总结

目的 检索有关糖尿病患者急性卒中后血糖监测及管理的相关证据,并汇总最佳证据供临床参考。方法 根据循证护理的方法,按照“6S”证据模型,利用计算机检索国内外有关糖尿病患者急性卒中后血糖监测及管理的临床决策、指南、系统评价、随机对照试验、证据总结和专家共识,由2名经过循证护理系统化培训的研究员对纳入的文献进行独立评价,并对通过质量评价的文献进行证据提取。结果 共纳入13篇文献,其中临床决策1篇、指南6篇、系统评价1篇、随机对照试验2篇、证据总结1篇和专家共识2篇,并从中汇总23条证据,最后从6个维度总结了14条最佳证据。结论 对于糖尿病患者急性卒中后的血糖管理要遵循个性化和多样化原则,在降糖治疗的同时要充分考虑患者的实际情况,为其制定个性化的降糖方案;同时也要注意低血糖带来的危害,加强血糖监测,避免低血糖的发生。     

颈髓损伤循证治疗的实践策略

目的探讨颈髓损伤循证治疗的实践策略。方法2013年1月3日收治1例颈髓损伤患者,全面评估病情,检索数据库获得循证医学证据,制定最佳治疗策略,治疗始末均全面实施该方案,评价治疗结局。结果根据检索循证医学证据,颈髓损伤治疗目标即挽救残留功能、防治并发症,努力促进神经功能恢复。依据实时病情,循证制定动态治疗方案,实施包括绝对卧床休息、颈部制动、大剂量激素冲击、神经营养药物、辅以中医药康复、并发症防治处理等循证综合治疗。经半年左右随访,患者病情稳定,可下床站立及行走,已恢复一定生活自理能力。结论应用循证医学方法制定颈髓损伤循证治疗策略,保证患者最大程度受益,更具科学性,值得推广。     

1例老年2型糖尿病频发低血糖患者的循证护理实践

为1例老年2型糖尿病频发低血糖患者制定循证护理方案。通过检索Up to Date、JBI循证卫生保健中心数据库、加拿大安大略注册护士协会、英国国家临床医学研究所指南库、苏格兰校际间指南网、医脉通临床指南网等关于老年2型住院糖尿病患者低血糖管理方面的所有证据,由4名研究者对纳入的文献质量进行独立评价,并对符合质量标准的文献进行证据提取,共纳入19篇文献,提取17条符合患者的最佳证据。在证据的基础上结合患者意愿,糖尿病健康教育团队为患者实施综合评估,制定针对性的低血糖预防处理方案,包括制定个体化的血糖控制目标,应用动态血糖监测系统、针对性的饮食、药物指导等,经过10 d的积极干预,患者住院期间低血糖发生频次减少、血糖波动幅度减小。     

晚期帕金森病的循证治疗

通过TRIP和SUM search,检索MEDLINE和Cochrane图书馆,获得治疗晚期帕金森病长期美多巴治疗后合并开-关现象、异动症以及伴抑郁的证椐,并对这些证据进行了评价.据所获证据,结合医生的经验及病人的愿望制定了循证治疗方案,患者症状得到明显缓解.     

以循证医学方法为百草枯中毒制定治疗方案

目的 根据循证医学理论和原则,为急性百草枯(PQ)中毒患者制定循证治疗方案并实施相应的循证治疗,以期在目前现有证据的支持下,达到最佳化治疗的目的.方法 选择1例PQ中毒患者,根据患者的临床情况,提出血液净化治疗和免疫抑制剂治疗的临床问题.检索Cochrane临床试验数据库(2010年第1期)、MEDLINE (1950年至2010年1月)和中国生物医学文献数据库(CBM,1978年至2010年),纳入PQ中毒治疗的系统评价、Meta分析和临床随机对照试验(RCT),根据所获证据为该例患者制定循证治疗的方案.治疗结束并随访1年.结果 根据检索结果分析,共纳入7篇PQ中毒相关文献.证据显示,血液净化可延长患者的存活时间,但不能降低病死率;糖皮质激素与环磷酰胺联合冲击疗法可提高患者的生存率.结合该例患者的病情和意愿,给予相应循证治疗,治疗结束后好转出院,随访1年无并发症出现.结论 以目前循证医学最佳证据、结合患者情况制定治疗方案,能提高PQ中毒患者的近期疗效,但远期预后尚需更长时间的随访观察.     

糖尿病及长效胰岛素类似物是否增加病人罹患肿瘤的风险?——1例糖尿病合并胰腺癌患者的循证治疗

目的糖尿病与肿瘤的关系以及长效胰岛素类似物是否致癌是目前颇有争议的热点问题,结合1例糖尿病合并胰腺癌患者的病情,用循证临床实践的方法,对糖尿病与肿瘤的关系及长效胰岛素类似物是否致癌进行讨论。方法计算机检索Cochrane图书馆(2010年第3期)、OVID-EBM Reviews(1991～2010.9)、MEDLINE(1950～2010.9)、CNKI(2000～2010.9),查找高质量临床证据,并根据患者意愿为患者制定最佳治疗方案。结果共纳入8个RCT,4个Meta分析,1个RCT联合分析。证据表明:①糖尿病与恶性肿瘤的发病有一定关系;②目前尚无证据表明长效胰岛素类似物与肿瘤发生间存在关联;③糖尿病患者严格控制血糖不增加罹患肿瘤的风险,但高血糖也无导致肿瘤的证据;④合并肿瘤的糖尿病患者是否停用长效胰岛素类似物,需征求专科医师意见,患者不宜自行调整。该患者糖尿病治疗措施不变。结论目前尚无高质量证据表明糖尿病、使用长效胰岛素类似物(甘精胰岛素)、糖尿病患者严格控制血糖与肿瘤的发生有关系。正在接受甘精胰岛素治疗的合并肿瘤的糖尿病患者是否需要调整治疗方案尚需更多证据。     

一例Barrett食管患者的循证治疗

目的借助循证医学方法为1例成年男性Barrett食管患者确定治疗方案。方法在充分评估患者情况后,提出临床问题,从Cochrane图书馆(2009年第3期)、PubMed(1995～2010)和SCIE(1995～2010)上检索Barrett食管治疗的系统评价和RCT。根据当前最好证据结果及病人意愿为患者制定治疗目标和治疗方案。结果共检出与不同问题相关的RCT 21篇,系统评价/Meta分析6篇。通过对检索结果进行分析并结合患者意愿,为患者制定了合理的治疗方案:改善生活习惯,内镜下行氩等离子凝固术(APC)结合抑酸药物(奥美拉唑,40 mg,bid)治疗6周。3个月后内镜复查,患者症状减轻,病灶消失。又经过12个月随访证实,患者满意该方案适合该患者。结论采用循证治疗方法,为初诊男性Barrett食管患者确定合理的治疗目标和方案,能有效减轻患者症状,提高生活质量。     

化疗致周围神经病变患者症状管理循证方案的构建

目的 构建成人肿瘤患者化疗致周围神经病变症状管理循证实践方案。方法 以症状管理理论为框架,根据PIPOST循证问题进行结构化的文献检索,检索时间为建库至2022年1月31日。并对文献做质量评价,归纳综合最终纳入文献的相关证据,形成最佳实践推荐总结,制定符合现实情况且可行的具体实施策略,通过专家焦点小组访谈评价方案并修改,构建最终“成人肿瘤患者化疗致周围神经病变症状管理循证实践方案”。结果 共纳入1篇临床决策,2篇临床指南,2篇专家共识,1篇证据总结,1篇实践推荐,1篇系统评价的再评价和15篇系统评价/meta分析。形成最佳实践证据推荐包括38条证据,构建的方案包含6个维度及1份健康教育手册。方案总体设计专家评价得分为97.33%,各维度专家评价得分别为98.67%、98.10%、99.78%、99.26%、100%和99.56%,健康教育手册得分为99.89%。结论 成人患者化疗致周围神经病变症状管理循证方案遵循症状管理理论,在评估证据的可行性、适宜性、临床意义及有效性的前提下,充分引入证据,以达到证据在临床的转化,今后应进一步评价方案的临床可行性。     

Treatment of chronic painful diabetic neuropathy with isosorbide dinitrate spray: a double-blind placebo-controlled cross-over study

OBJECTIVE: Considerable evidence implicates impaired nitric oxide (NO) generation in the pathogenesis of diabetic neuropathic pain. We therefore conducted a pilot study to examine the effects of isosorbide dinitrate (ISDN), a NO donor with local vasodilating properties, in spray form in the management of chronic neuropathic pain. RESEARCH DESIGN AND METHODS: The study was of double-blind, randomized, placebo-controlled, and two-period cross-over design. After a 2-week run-in period, 22 diabetic patients (13 men, 20 with type 2 diabetes, age [mean +/- SE] 63.7 +/- 1.8 years, duration of diabetes 9.1 +/- 1.5 years, duration of painful neuropathy 2.6 +/- 0.4 years) were randomized to receive ISDN or placebo sprays for 4 weeks, exchanging their treatment for a further 4 weeks after a 2-week wash-out period. The patients administered the spray to both feet before bedtime. Biweekly pain and other sensory symptoms were assessed using a visual analog scale (VAS) and the Lickert scale, respectively. RESULTS: ISDN spray reduced overall neuropathic pain (P = 0.02) and burning sensation (P = 0.006). No treatment difference was observed with other sensory modalities (hot/cold sensation, tingling, numbness, hyperesthesia, and jabbing-like sensation). At study completion, 11 patients (50%) reported benefit and wished to continue using the ISDN spray, 4 (18%) preferred the placebo spray, and the remaining 7 (32%) were undecided. CONCLUSIONS: ISDN spray offers an alternative and effective pharmacological option in relieving overall pain and burning sensation in the management of painful diabetic neuropathy. The potential of ISDN spray in alleviating other specific sensory symptoms associated with diabetic peripheral neuropathy merits further study.     

Relief of painful diabetic peripheral neuropathy with pregabalin: a randomized, placebo-controlled trial.

This was a 6-week, randomized, double-blind, multicenter study evaluating the efficacy of pregabalin in the treatment of painful diabetic neuropathy. Two hundred forty-six men and women with painful diabetic neuropathy received pregabalin (150 or 600 mg/day by mouth) or placebo. The primary efficacy variable was mean pain score at the end of treatment. Efficacy results indicate that pregabalin 600 mg/day significantly decreased mean pain score to 4.3 (vs 5.6 for placebo, P = .0002) and increased the proportion of patients who had a > or =50% decrease from baseline pain (39% vs 15% for placebo, P = .002). Pregabalin also significantly reduced sleep interference, past week and present pain intensity, sensory and affective pain scores, and bodily pain and decreased by > or =50% the number of patients describing their pain as gnawing, sickening, fearful, and punishing-cruel. More patients receiving pregabalin 600 mg/day than placebo showed improvement, as rated on the Clinical and Patient Global Impression of Change scales, 73% vs 45% and 85% vs 47%, respectively. Pregabalin 150 mg/day was essentially no different from placebo. Dizziness was the most common side effect. These study results show pregabalin 600 mg/day to be safe and effective in reducing the pain and other associated symptoms of painful diabetic neuropathy. PERSPECTIVE: Painful diabetic peripheral neuropathy is a challenging neuropathic pain syndrome. This randomized controlled trial demonstrates that pregabalin, a new drug that interacts with the alpha2-delta protein subunit of the voltage-gated calcium channel, is an efficacious and safe treatment for the pain of this condition.     

Clinical efficacy of fidarestat, a novel aldose reductase inhibitor, for diabetic peripheral neuropathy: a 52-week multicenter placebo-controlled double-blind parallel group study

OBJECTIVE: The purpose of this study was to evaluate the efficacy of fidarestat, a novel aldose reductase (AR) inhibitor, in a double-blind placebo controlled study in patients with type 1 and type 2 diabetes and associated peripheral neuropathy. RESEARCH DESIGN AND METHODS: A total of 279 patients with diabetic neuropathy were treated with placebo or fidarestat at a daily dose of 1 mg for 52 weeks. The efficacy evaluation was based on change in electrophysiological measurements of median and tibial motor nerve conduction velocity, F-wave minimum latency, F-wave conduction velocity (FCV), and median sensory nerve conduction velocity (forearm and distal), as well as an assessment of subjective symptoms. RESULTS: Over the course of the study, five of the eight electrophysiological measures assessed showed significant improvement from baseline in the fidarestat-treated group, whereas no measure showed significant deterioration. In contrast, in the placebo group, no electrophysiological measure was improved, and one measure significantly deteriorated (i.e., median nerve FCV). At the study conclusion, the fidarestat-treated group was significantly improved compared with the placebo group in two electrophysiological measures (i.e., median nerve FCV and minimal latency). Subjective symptoms (including numbness, spontaneous pain, sensation of rigidity, paresthesia in the sole upon walking, heaviness in the foot, and hypesthesia) benefited from fidarestat treatment, and all were significantly improved in the treated versus placebo group at the study conclusion. At the dose used, fidarestat was well tolerated, with an adverse event profile that did not significantly differ from that seen in the placebo group. CONCLUSIONS: The effects of fidarestat-treatment on nerve conduction and the subjective symptoms of diabetic neuropathy provide evidence that this treatment alters the progression of diabetic neuropathy.     

Pregabalin: a novel gamma-aminobutyric acid analogue in the treatment of neuropathic pain, partial-onset seizures, and anxiety disorders

BACKGROUND: The US Food and Drug Administration (FDA) approved pregabalin in December 2004 for the treatment of neuropathic pain associated with diabetic peripheral neuropathy and postherpetic neuralgia. Pregabalin is the first drug approved in the United States and in Europe for both conditions. In June 2005, pregabalin was approved as an adjunctive treatment in adults with partial-onset seizures. The FDA currently is considering the approval of pregabalin as adjunctive therapy in adults with generalized anxiety disorder (GAD) or social anxiety disorder (SAD). OBJECTIVES: The goals of this review were to summarize the pharmacology, pharmacokinetics, efficacy, and tolerability of pregabalin; review its approved uses in the management of neuropathic pain and refractory partial-onset seizures; and investigate its potential use in patients with GAD or SAD. METHODS: Relevant English-language literature was identified through a search of MEDLINE (1993-June 2006) and International Pharmaceutical Abstracts (2000-June 2006). The search terms included pregabalin, Lyrica, S-(+)-3 isobutyl-gaba, PN, DPN, diabetic peripheral neuropathy, PHN, postherpetic neuralgia, partial seizures, epilepsy, generalized anxiety disorder, and CI-1008. RESULTS: In 4 clinical trials in a total of 1068 patients with diabetic peripheral neuropathy, the patients receiving pregabalin 300 to 600 mg/d had significantly greater improvement in mean pain scores than placebo recipients (P < or = 0.01). Patients with postherpetic neuralgia receiving pregabalin 450 to 600 mg/d had significantly greater improvement in relief of pain and pain-related sleep interference than placebo recipients (P < or = 0.002). Patients with refractory partial-onset seizures who received pregabalin 150 to 600 mg/d (divided into 2 or 3 doses) concomitantly with antiepileptic drugs had significantly fewer seizures than placebo recipients (P < or = 0.001). In the 3 studies that evaluated the efficacy of pregabalin in patients with GAD or SAD, the patients receiving pregabalin 200 to 600 mg/d (divided into 2 or 3 daily doses) had a significantly greater reduction in mean pain scores on the Hamilton Anxiety Scale than placebo recipients (P < or = 0.01). Across all the reviewed clinical trials, the most commonly reported adverse effects (AEs) were those affecting the central nervous system, including somnolence (< or =50%), dizziness (< or =49%), and headache (< or =29%). AEs resulted in withdrawal from the study in < or =32% of patients. CONCLUSIONS: Pregabalin appears to be an effective therapy in patients with diabetic peripheral neuropathy, postherpetic neuralgia, and adults with refractory partial-onset seizures. The available data suggest that pregabalin may be beneficial as an adjunctive therapy in adult patients with GAD or SAD.     

Differential diagnosis of atypical focal peripheral neuropathy: Case report

Carpal tunnel syndrome (CTS) is the most frequent form of focal peripheral neuropathy but is commonly misdiagnosed. The aim of this case report was to describe the differential diagnosis of CTS and atypical focal peripheral neuropathy in a 34-year-old female. Although the patient's medical diagnosis was CTS, she did not report night pain, did not exhibit hand atrophy, had no sensory loss, did not meet the five criteria of the clinical prediction rule for CTS, and demonstrated symptoms associated with radial and median nerve pain. The patient's concordant symptoms were associated with wrist passive accessory stiffness and functional activities that required repetitive end range movements. Interventions included treatment of two priority impairments: 1) pain and 2) wrist accessory stiffness. After five treatments, the patient no longer reported pain with activities and was able to return to work with no restrictions. Although the patient in this case report exhibited isolated features consistent with CTS, compelling cumulative evidence suggested a distinct diagnosis. Limited evidence exists to support the use of mobilization, strengthening, and pain reduction-based modalities for the treatment of focal peripheral neuropathy; subsequently, treatments must be individually effective when targeted toward the patient's priority impairments. The diagnosis of CTS is challenging because there are a variety of possible clinical presentations. Using evidence-based indices, such as the clinical prediction rule for CTS and other comparative history and physical measures, should improve the likelihood of accurate diagnosis and treatment.     

Differential diagnosis of atypical focal peripheral neuropathy: case report

Carpal tunnel syndrome (CTS) is the most frequent form of focal peripheral neuropathy but is commonly misdiagnosed. The aim of this case report was to describe the differential diagnosis of CTS and atypical focal peripheral neuropathy in a 34-year-old female. Although the patient's medical diagnosis was CTS, she did not report night pain, did not exhibit hand atrophy, had no sensory loss, did not meet the five criteria of the clinical prediction rule for CTS, and demonstrated symptoms associated with radial and median nerve pain. The patient's concordant symptoms were associated with wrist passive accessory stiffness and functional activities that required repetitive end range movements. Interventions included treatment of two priority impairments: 1) pain and 2) wrist accessory stiffness. After five treatments, the patient no longer reported pain with activities and was able to return to work with no restrictions. Although the patient in this case report exhibited isolated features consistent with CTS, compelling cumulative evidence suggested a distinct diagnosis. Limited evidence exists to support the use of mobilization, strengthening, and pain reduction-based modalities for the treatment of focal peripheral neuropathy; subsequently, treatments must be individually effective when targeted toward the patient's priority impairments. The diagnosis of CTS is challenging because there are a variety of possible clinical presentations. Using evidence-based indices, such as the clinical prediction rule for CTS and other comparative history and physical measures, should improve the likelihood of accurate diagnosis and treatment.     

前列腺素联合甲钴胺治疗糖尿病周围神经病变的临床疗效

目的观察前列腺素E1联合甲钴胺治疗糖尿病周围神经病变的临床疗效及其安全性。方法 96例糖尿病周围神经病变患者分为治疗组(n=55)及对照组(n=41),两组均给予胰岛素控制血糖,控制血压等基础治疗,治疗组同时给予前列腺E110μg/d静脉滴注及甲钴胺500μg/d肌肉注射治疗共4周,4周后改为甲钴胺500μg,3次/d口服继续治疗8周,于治疗前及治疗后分别测定双下肢运动神经传导速度、感觉神经传导速度及临床症状变化。结果治疗后患者周围神经病变如麻木、疼痛、感觉异常均有明显改善,神经传导速度有不同程度的提高,未出现明显不良反应。结论前列腺素E1及甲钴胺的联合应用对于糖尿病周围神经病变的疗效确切,临床治疗安全、可靠。     

Lacosamide in painful diabetic peripheral neuropathy: a phase 2 double-blind placebo-controlled study

BACKGROUND: Peripheral diabetic neuropathy affects between 20% and 45% of patients with diabetes. OBJECTIVE: To ascertain the effect of lacosamide on pain associated with peripheral diabetic neuropathy. METHODS: One hundred nineteen patients with a 1 to 5-year history of pain attributed to diabetic neuropathy and a score of > or =4 on the Likert pain scale entered the multicenter, randomized, double-blind, placebo-controlled trial. Lacosamide (N=60) titrated from 100 to 400 mg/d or maximum tolerated dose and placebo (N=59) were the trial interventions. Primary efficacy criterion was change in pain score on the 11-point Likert pain scale. Secondary assessments included Short-Form McGill Pain and Short-Form-36 Quality of Life Questionnaires, sleep/activity interference, pain intensity, Patient and Clinical Global Impression of Change, and Profile of Mood. Patients receiving at least 1 dose of medication underwent safety evaluation. RESULTS: Ninety-four patients (lacosamide 46; placebo 48) completed the trial. Lacosamide had significantly (P=0.039) better pain relief versus placebo (primary outcome). Improvements were also seen in secondary outcome measures. Adverse events occurred in 52 lacosamide and 44 placebo patients. Common adverse events, occurring in > or =5% of patients, were headache (lacosamide 18%, placebo 22%), dizziness (lacosamide 15%, placebo 8%), and nausea (lacosamide 12%, placebo 7%). Five lacosamide and 3 placebo patients withdrew for adverse events. DISCUSSION: Lacosamide seems to attenuate pain in diabetic neuropathy in doses up to 400 mg/d and improves quality of life issues.     

Transdermal clonidine compared to placebo in painful diabetic neuropathy using a two-stage ‘enriched enrollment’ design

Because a variety of mechanisms may generate pain in neuropathic pain syndromes, conventional clinical trial methods may fail to identify some potentially useful drugs; a drug affecting just a single mechanism may work in too few patients to yield a statistically significant result for the trial. To test a previous clinical observation that approximately one-quarter of patients with painful diabetic neuropathy appear responsive to clonidine, we conducted a formal clinical trial of transdermal clonidine in painful diabetic neuropathy patients using a 2-stage enriched enrollment design. In the first stage (study I), 41 patients with painful diabetic neuropathy completed a randomized, 3-period crossover comparison of transdermal clonidine (titrated from 0.1 to 0.3 mg/day) to placebo patches. Twelve apparent responders from study I were entered into the ‘enriched enrollment’ second stage (study II), consisting of an additional 4 double-blind, randomized, 1-week treatment periods with transdermal clonidine and placebo. Study I showed that in the overall group of 41 patients, pain intensity differed little during clonidine and placebo treatment. In study II, however, the 12 apparent responders from study I had 20% less pain with clonidine than placebo (95% confidence interval (CI): 4–35% pain reduction; P = 0.015), confirming that their pain was responsive to clonidine. None of the 3 consistent clonidine responders who were tested with the -adrenergic blocker phentolamine had relief of pain, suggesting that clonidine's pain relief is not mediated by a decrease in sympathetic outflow. A post-hoc analysis of many variables suggested that patients who described their pain as sharp and shooting may have a greater likelihood of responding to clonidine. The results of this study support the hypothesis that there is a subset of patients with painful diabetic neuropathy who benefit from systemic clonidine administration and illustrate the value of an enriched enrollment technique in analgesic trials.