对《对〈中国乙型肝炎病毒母婴传播防治指南(2019年版)〉的商榷》一文的回复

2011年,美国医学研究所(Institute of Medicine,IOM)对已使用20年的临床实践指南的定义进行了修改,强调指南应基于系统评价证据,平衡不同干预措施利弊,在此基础上形成能够为患者提供最佳保健服务的推荐意见[1]。《中国乙型肝炎病毒母婴传播防治指南(2019年版)》(下称《指南》)[2]由中华医学会感染病学分会发起,联合感染、肝病、妇产、生殖及循证医学等多学科专家,严格遵守IOM对指南的最新定义和《世界卫生组织指南制订手册》[3]的规范和流程,运用证据推荐分级的评估、制订与评价方法(Grading of Recommendations Assessment,Development and Evaluation,GRADE)[4],历时近2年完成。《指南》发表后,在巡讲和宣贯过程中,受到相关领域专家及临床医师的积极评价,并逐步应用于临床实践。近期我们也注意到部分专家对指南的某些内容提出商榷和争鸣,我们高度重视并认真听取。本文就周乙华教授等《对〈中国乙型肝炎病毒母婴传播防治指南(2019年版)〉商榷》(下文简称《商榷》)一文中提出的问题,遵循学术争鸣原则,逐一予以回复和说明,以示对原作者的尊重,也是对《指南》广大读者和使用者负责。     

《2015年日本胃肠病学会肝硬化循证医学临床实践指南》摘译

本指南是日本胃肠病学会根据2015年肝硬化循证医学临床实践指南修订的更新版本,主要是为肝硬化及其并发症在临床实践中提供最佳的治疗方案和干预措施.美国或欧洲肝硬化临床实践指南将肝硬化分为乙型肝炎、丙型肝炎、酒精性肝病、门静脉高压、腹水/肝肾综合征和肝性脑病等不同部分分别进行阐述.而本指南首次将肝硬化作为一个整体,对肝硬化及其并发症的管理进行综合性概述.其主要包括6部分:概念、诊断、治疗、并发症、预后和肝移植.现将文中的推荐意见及相关内容进行摘译,以供相关专业人士参考.本指南根据GRADE系统进行推荐强度及证据质量分级.证据质量分为A(高)、B(中)、C(低)及D(极低)等级;推荐强度分为1(强烈推荐)和2(较弱推荐)等级.     

对《对中国乙型肝炎病毒母婴传播防治指南(2019年版)的商榷》一文的回复

2011年,美国医学研究所(Institute of Medicine,IOM)对已使用20年的临床实践指南的定义进行了修改,强调指南应基于系统评价证据,平衡不同干预措施利弊,在此基础上形成能够为患者提供最佳保健服务的推荐意见。《中国乙型肝炎病毒母婴传播防治指南(2019年版)》(下称《指南》)由中华医学会感染病学分会发起,联合感染、肝病、妇产、生殖及循证医学等多学科专家,严格遵守IOM对指南的最新定义和《世界卫生组织指南制订手册》的规范和流程,运用证据推荐分级的评估、制订与评价方法(Grading of Recommendations Assessment,Development and Evaluation,GRADE),历时近2年完成。     

改善全球肾脏病预后组织慢性肾脏病贫血指南(概要)

2012年改善全球肾脏病预后组织(KDIGO)制定了慢性肾脏病(CKD)贫血的临床实践指南,其目的在于为有贫血或具有贫血风险的所有CKD患者(非透析、透析、肾移植受者和儿童)提供诊断、评价、管理和治疗方面的指导.指南的制订遵循了明确的证据审查和评价流程.指南包含CKD贫血的诊断和评估、药物治疗[铁剂、红细胞生成刺激剂(ESA)和其他药物]和作为治疗手段的红细胞输注.指南的各章节提出相应的治疗方法,其中的建议基于相关试验的系统评价.根据GRADE(推荐、评估、发展、评价分级)系统评估证据质量和推荐强度.本指南对目前证据的争议和局限性进行了探讨,也为今后的研究提供了更多的建议.     

临床实践指南制订方法——形成推荐意见的共识方法学

在临床实践指南制订过程中,通过专家共识形成推荐意见是其中必不可少的环节。本文以指南手册为基础,从定义、特点、优缺点、一般流程等方面介绍了主要的共识方法(非正式共识法、德尔菲法、名义群体法、共识形成会议法、改良版德尔菲法和GRADE网格等),并全面系统解释了美国临床肿瘤学会(ASCO)的改良版德尔菲法,旨在为指南制订者在使用共识方法时提供参考。     

对2017美国高血压指南与我国高血压防治策略的思考

正在2017年美国心脏协会(AHA)科学年会上,美国心脏病学会(ACC)和AHA联合其他9个临床医学专业学会发布了最新制订的《成人高血压预防、检测、评估和处理指南》[1]。这是自从2013年美国政府机构NIH宣布不再主持制订临床疾病预防和管理指南后,由美国民间权威学术团体制订的第一部美国临床高血压防治指南。该指南根据目前可获得的所有高血压相关流行病学数据、队列或病例对照研究资     

中国高尿酸血症与痛风诊疗指南(2019)

近年来,中国高尿酸血症与痛风患病率急剧增加,亟需制订基于国人研究证据的临床循证指南。为此,中华医学会内分泌学分会遵循国际通用GRADE分级方法,采用临床循证指南制订流程,由方法学家在内的多学科专家参与制订了本指南。本指南包含3条推荐总则和针对10个临床问题的推荐意见,涵盖了高尿酸血症与痛风的诊断、治疗和管理;首次提出了亚临床痛风、难治性痛风的概念和诊治意见;首次对碱化尿液相关问题进行了推荐;首次对痛风常见合并症药物选择进行了推荐。本指南旨在为临床医生和相关从业者对高尿酸血症与痛风的诊疗决策提供最佳依据。     

美国肝病学会发布的2011临床实践指南:对慢性1型丙型肝炎病毒感染的更新治疗

此临床实践指南是由美国肝病学会发布并获得了美国感染病学会、美国胃肠病学会、全国病毒性肝炎委员会的支持. 这些建议提供了制定指南的数据支持,依据如下:(1)对全世界有关这一主题的文献进行全面回顾及分析(检索至2011年6月前的文献);(2)美国大学健康评定及制定实践指南的医师手册;(3)指南方针,包括美国肝脏病研究协会关于发展及运用实践指南的方针以及美国胃肠病学会的医疗实践指南;C4)作者对丙型肝炎的经验.     

2012年美国实践指南:非酒精性脂肪性肝病诊疗简介

前言 本指南中的推荐建议旨在为临床医师和相关医护人员提供关于非酒精性脂肪性肝病NAFLD诊断、治疗和预防的优先处理方案.AASLD实践指南委员会采纳了推荐分级的评估、制定与评价(GRADE)工作组的分类并稍作修改.GRADE系统中推荐意见的强度分为强(1)或弱(2);证据质量分为高(A)、中(B)或低(C)3级(表1).     

2022中国幽门螺杆菌感染治疗指南

幽门螺杆菌感染是一种感染性疾病, 全球感染率高达50%, 其与消化不良、胃炎、消化性溃疡和胃癌的发生密切相关。根除幽门螺杆菌可有效控制相关疾病进展, 降低相关疾病发生风险。然而, 全球抗生素耐药率的升高使幽门螺杆菌感染根除效果面临巨大挑战。虽然幽门螺杆菌感染率在发达国家逐渐下降, 但在发展中国家仍居高不下, 造成了沉重的公共卫生负担。本指南的制定旨在为幽门螺杆菌感染的根除治疗提供指导。本临床实践指南按照世界卫生组织推荐的制定流程, 采用国际公认的推荐等级的评估、制定与评价(GRADE)系统评估证据质量, 并利用证据到决策框架制定临床推荐意见, 既减小偏倚, 又提高临床实践指南制定过程的透明性。使用国际实践指南报告规范(RIGHT)声明和临床指南研究与评价系统Ⅱ(AGREE Ⅱ)作为报告和行为指南, 以确保其完整性和透明度。本临床实践指南包含12项关于幽门螺杆菌感染根除治疗的建议;值得强调的是, 铋剂安全、有效、价格低廉, 本临床实践指南推荐铋剂四联方案成为幽门螺杆菌感染根除治疗的首选。在幽门螺杆菌感染初次经验性根除治疗中, 高剂量双联方案与铋剂四联方案疗效相当。本临床实践指南中的12项...     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.