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。     

血管内栓塞联合手术切除治疗脑动静脉畸形的Meta分析

目的使用Meta分析的方法评价血管内栓塞联合手术切除治疗脑动静脉畸形(AVM)的疗效。方法检索MEDLINE和中国生物医学文献数据库,获得以往发表的相关论文。根据临床和统计标准进行合并分析。结果总计有9篇文献纳入Meta分析。血管内栓塞联合手术组中高级别脑AVM所占比例和单纯手术组中其所占比例的合并危险差为36%[95%CI为6%～66%](Z=2.36,P=0.02);两治疗组术后长期神经功能缺失率的合并优势比为0.38[95%CI为0.23～0.61](Z=3.95,P<0.0001)。结论血管内栓塞联合手术切除治疗脑AVM能扩大手术治疗的适应证,同时保持较高的全切率,并且与单纯手术治疗相比预后显著较好。     

脑膜中动脉栓塞治疗难治性慢性硬膜下血肿的Meta分析

目的研究脑膜中动脉(MMA)栓塞治疗难治性慢性硬膜下血肿(CSDH)的有效性及安全性。方法应用系统评价的方法,检索知网、维普、PubMed、Embase等中英文数据库收录的脑膜中动脉栓塞治疗慢性硬膜下血肿的相关文献,采用RevMan 5.3软件进行Meta分析。结果共纳入14篇文献,其中5篇为对照研究,9篇为病例系列研究;将5篇对照研究的栓塞组和传统手术组患者进行Meta分析。结果显示,栓塞组患者的血肿复发率(3.0%)明显低于传统手术组(23.5%),差异有统计学意义(OR=0.12;95%CI0.05～0.25;P<0.000 01;I2=47%);两组患者手术并发症发生率(3.4%,5.3%)的差异无统计学意义(OR=0.51;95%CI0.23～1.15;P=0.11;I2=0%)。合并14篇文献,栓塞治疗患者的术后血肿复发率为3.9%,手术并发症发生率为2.4%,均低于传统手术治疗患者;其中难治性慢性硬膜下血肿患者栓塞术后的复发率及手术并发症发生率均为4.5%。结论脑膜中动脉栓塞治疗慢性硬膜下血肿安全、有效,尤其适用于多次复发或存在高复发风险的难治性硬膜下血肿。     

经腹腹腔镜与后腹膜腹腔镜根治性肾切除治疗肾癌的Meta分析

背景：目前对于经腹腹腔镜与后腹膜腹腔镜根治性肾切除治疗肾癌的效果及安全性存在分歧，从而制约了对其进一步研究。 目的：系统评价经腹腹腔镜肾癌根治术与后腹膜腹腔镜肾癌根治术治疗肾癌的效果。 方法：于2010-01以“腹腔镜肾癌根治术，laparoscopic radical nephrectomy”为关键词，计算机检索Medline，EMbase，Cochrane database，CMB，CNKI截止2009-12-31以前的随机、半随机对照研究文献，利用RevMan4.2.2软件进行了Meta分析。 结果与结论：共筛选出5个前瞻性随机对照研究，Meta分析结果显示，在平均出血量[SMD=-0.22，95%CI(-0.52，0.09)]、术后标本质量[SMD=0.35，95%CI(-0.17，0.86)]方面差异无显著性意义，而在平均手术时间[SMD=0.72，95%CI(0.41，1.03)]、并发症发生率[OR=2.16，95%CI(1.03，4.51)]方面差异有显著性意义。提示经腹腹腔镜肾癌根治术和后腹膜腹腔镜肾癌根治术治疗肾癌在平均出血量及术后标本质量方面无明显差异，后腹膜腹腔镜肾癌根治术的平均手术时间及并发症发生率均低于经腹腹腔镜肾癌根治术。     

内镜手术与显微手术治疗垂体腺瘤疗效的Meta分析

目的比较内镜手术与显微手术治疗垂体腺瘤的安全性和有效性。方法计算机检索Pubmed、EMbase、CBM、CNKI、万方及VIP等数据库,查找所有比较内镜手术与显微手术治疗垂体瘤的随机对照试验或病例对照研究,检索时限均为建库至2014年5月31日。按纳入排除标准由两人独立进行研究的筛选、资料提取和质量评价后,采用Rev Man5.2软件进行Meta分析。结果共纳入8个研究、712例患者,结果显示,与显微手术相比,内镜手术肿瘤全切率[优势比(OR)=1.23;95%可信区间(CI)(0.62~2.46);P=0.56]、手术时间(P0.05)、术后激素水平改善率[OR=1.21;95%CI(0.58~2.55);P=0.61]、术后脑脊液漏发生率[OR=1.44;95%CI(0.80~2.58);P=0.23]、脑/脑膜炎发生率明显减少[OR=1.15;95%CI(0.38~3.48);P=0.81]、尿崩发生率[OR=1.17;95%CI(0.71~1.94);P=0.53]均无明显改善,而术后鼻出血发生率[OR=0.24;95%CI(0.07~0.78);P=0.02]和术后住院天数明显缩短(P0.05)。结论内镜手术与显微手术相比其术后鼻出血患者较少,术后住院天数短。     

静脉注射免疫球蛋白与血浆置换治疗重症肌无力的meta分析

目的系统评价静脉注射免疫球蛋白(IVIg)与血浆置换(PLEX)治疗重症肌无力(MG)的有效性和安全性。方法计算机检索Cochrane图书馆、Pubmed、Embase、CNKI及万方数据库,系统收集国内外有关这两种方式治疗MG的相关文献。按系统评价的方法,由2名研究员独立对文献进行质量评价和资料提取后,采用Rev Man 5.2软件进行Meta分析。结果共纳入9篇文献,合计2132例MG患者。Meta分析结果显示,IVIG与PLEX治疗MG的有效性无明显差异[OR=0.94,95%CI(0.57,1.32),P=0.79];IVIg与PLEX的治疗相关不良反应发生率也无明显差异[OR=0.91,95%CI(-0.37,2.21),P=0.83]。结论 IVIG与PLEX对MG的治疗效果以及治疗相关的不良反应发生率均无明显差异,因此,临床上可根据具体情况选择合适的治疗方式。     

前、后入路对胸腰椎骨折合并脊髓损伤患者神经功能恢复的Meta分析

目的系统评价前、后路手术方案对于胸腰椎骨折所致脊髓损伤患者术后神经功能恢复的影响。方法计算机检索Pubmed、Cochrane 结果最终纳入文献11篇,10篇为中文文献,1篇为英文文献,共纳入704例患者。结果显示:前路手术在提高患者ASIA运动功能评分方面优于后路手术[MD=13.79,95%CI(8.97,18.61),P0.001];前路手术在提高患者ASIA触觉功能评分方面优于后路手术[MD=11.70,95%CI(6.85,16.56),P0.001];前路手术在矫正脊柱畸形的效果上优于前路手术[MD=12.61,95%CI(11.90,13.31),P0.001];前路手术在改善患者伤椎高度上优于后路手术[MD=1.00,95%CI(0.74,1.27),P0.001];后路手术在手术时间方面较前路手术更好[MD=24.05,95%CI(～22.67,70.77),P=0.006];后路手术组在术中出血量方面较前路手术组更好[MD=182.78,95%CI(77.73,287.83),P=0.0006];不良事件发生方面,两种方案之间的差异不具有统计学意义[MD=0.04,95%CI(～0.12,0.21),P=0.63]。结论研究显示前路手术方案对于胸腰椎骨折脊髓损伤患者神经功能恢复效果更好。由于纳入文献的局限性,需要更多的多中心、大样本的临床随机对照实验进一步证明。     

高压氧对小儿脑瘫疗效的Meta分析

目的探讨高压氧治疗小儿脑性瘫痪的疗效。方法检索PubMed、EMBase、中国知网、万方数据库及维普中文科技期刊数据库中有关高压氧治疗小儿脑性瘫痪的研究文献,按纳入标准对文献严格筛选后提取相关信息。采用RevMan5.2软件进行Meta分析。结果最终纳入11篇文献,Meta分析结果显示:高压氧+基础康复治疗对脑瘫患儿的运动能力[标准化均数差(SMD)=0.30,95%CI(0.08,0.52),P=0.007]、Gesell评分[OR=5.54,95%CI(2.76,11.14),P0.0001]和发育商[(SMD)=1.08,95%CI(0.86,1.31),P0.0001]均高于单纯基础治疗的患儿。结论高压氧治疗脑瘫有一定的疗效,但由于纳入的文献研究质量较低,样本量较少,故尚需要进一步高质量、大样本的研究来揭示高压氧对脑瘫的疗效。     

精神分裂症患者BDNF基因C270T多态性Meta分析

目的评价脑源性神经营养因子基因C270T多态性与精神分裂症的关系。方法检索国内外公开发表的关于精神分裂症患者C270T位点多态性病例对照研究的文献,对C270T位点C/T等位基因和CC/(CT+TT)基因型进行Meta分析,计算OR值,并按人种因素分亚组分析。结果共纳入16篇文献,包括3874例患者与4309名对照。C/T等位基因和CC/(CT+TT)基因型均与精神分裂症有关(均P0.01),OR值分别为1.65[95%CI(1.26,2.16)]和1.71[95%CI(1.27,2.30)]。亚组分析中,高加索人群等位基因和基因型与精神分裂症无统计学关联(均P=0.05);亚洲人群等位基因和基因型与发病风险有关(均P0.01),OR值分别为1.89[95%CI(1.30,2.75)]和1.97[95%CI(1.29,3.03)]。结论脑源性神经营养因子基因C270T位点多态性可能增加亚洲人群精神分裂症的易感性。     

神经内镜术及钻孔引流术治疗慢性硬膜下血肿临床效果的Meta分析

目的对比神经内镜术及钻孔引流术治疗慢性硬膜下血肿的临床疗效。方法检索2009～2019年知网、万方、维普、Pub Med、EMBase等中英文数据库,找出对比神经内镜术及钻孔引流术治疗慢性硬膜下血肿临床疗效的文献,由2名研究人员进行筛查和数据提取,并应用Revman5.3软件对纳入文献指标进行Meta分析。结果最终纳入10篇文献进行Meta分析,其中神经内镜组457例,钻孔引流组510例,Meta分析结果显示:与钻孔引流组相比,神经内镜组总体治愈率更高(OR=6.94,95%CI=[4.01,12.01],P0.01)、复发率更低(OR=0.15,95%CI=[0.08,0.25],P0.01)、术后并发症总体发生率更低(OR=0.35,95%CI=[0.22,0.54],P0.01)、住院时间更短(MD-1.71,95%CI=[-1.86,-1.56],P0.01)、手术时间更长(MD16.60,95%CI=[7.81,25.40],P0.01);两者在术后出血发生率(OR=0.36,95%CI=[0.11,1.15],P0.05)、术腔积气积液发生率(OR=0.66,95%CI=[0.41,1.05],P0.05)、感染发生率(OR=0.41,95%CI=[0.16,1.04],P0.05)方面无明显差异。结论现有文献证据表明,与钻孔引流术相比,神经内镜术总体治愈率更高、手术时间更长,并且能有效降低复发率及术后并发症总体发生率、缩短患者住院时长,但两种治疗方式在改善术后术腔积液积气、出血及感染发生率方面差异不明显。     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.