1例恶性胸膜间皮瘤的循证治疗

目的为1例确诊的恶性胸膜间皮瘤患者制定循证化疗方案。方法在充分评估患者病情的基础上，根据PICO原则，提出临床问题并转换成便于检索的形式，检索Cochrane图书馆（2007年第1期）、PubMed（1966～2007．2）和EMbase（1974年～2007年2月）。结果共检索出治疗恶性胸膜间皮瘤的随机对照试验5篇、系统评价4篇和卫生经济学评价1篇。根据检索结果，并结合患者病情和意愿，为患者制定出雷替曲塞联合顺铂的化疗方案，共进行5个周期的化疗，同时给予胸腔穿刺抽液及其它对症治疗。经过4月的随访证实，该方案适合患者。结论采用循证医学的方法为确诊的恶性胸膜间皮瘤患者制定最佳化疗方案可有效提高治疗效果。     

一例初诊老年前列腺增生患者的循证治疗

目的借助循证医学的方法为1例初诊老年前列腺增生患者确定治疗目标和治疗方案。方法在充分评估患者情况后,提出临床问题,从Cochrane Library、中国生物医学文献数据库、中国期刊网、PubMed、EMbase、ScienceDirect、Springer和ProQuest检索相关证据,检索时间截至2008年。评价证据的质量和适用性,据患者意愿制定治疗方案,随访患者。结果共检索出与不同问题相关的随机对照试验137篇,系统评价／Meta分析39篇。综合分析检索结果,为患者制订了合理的治疗方案。经1年随访证实,该方案适合患者。结论采用循证治疗的方法,为初诊老年前列腺增生患者确定合理的治疗方案,可有效提高治疗效果。     

合并肝硬化老年患者骨折术后镇痛的循证治疗

目的为1例合并肝硬化老年骨折患者制定镇痛方案,检索当前最佳证据,减少并发症发生。方法 2013年7月9日收治1例合并肝硬化老年骨折患者,针对患者术后镇痛治疗问题,全面评估病情,检索数据库获得循证医学证据,制定最佳治疗方案,治疗始末均全面实施该方案,评价治疗结局。结果检索纳入22篇文献,其中临床指南1篇,Cochrane系统评价3篇,系统评价5篇,小样本临床随机对照试验7篇,高质量观察性研究1篇,高质量的专题综述5篇。上述文献显示,在对肝硬化术后患者进行术后镇痛治疗时联合应用非阿片类镇痛药和阿片类镇痛药可以降低单独应用阿片类药物的使用量,从而降低阿片类药物不良反应的发生,增加镇痛安全性。环氧化酶2抑制剂不良反应较少,镇痛效果良好,可作为非阿片类镇痛药的首选药物。结论通过循证方法治疗合并肝硬化老年骨折患者的疼痛,更具有科学性和有效性。     

1例晚期非小细胞肺癌患者的循证治疗

目的借助循证医学方法为1例晚期非小细胞肺癌患者确定治疗方案。方法在充分评估患者情况后。提出临床问题,首检NCCN网站缩小检索范围,再计算机检索Cochrane图书馆（2008年第4期）、Medline（1990～2008年）和CNKI期刊全文数据库上进行检索,并对所获证据进行评价。结果共检出与非小细胞肺癌相关的随机对照试验21篇,系统评价或Meta分析5篇,Ⅲ期临床对照试验13篇,中文文献67篇。通过文献分析并结合患者意愿,为患者制定出合理的治疗方案。经9个月随访证实,该方案适合患者。结论采用循证治疗方法,为晚期非小细胞肺癌患者确定合理的治疗方案,不仅可有效提高治疗效果,同时有利于引导医患双方共同承担医疗不确定性的风险。     

美罗华在1例滤泡型淋巴瘤患者中的循证应用

目的为1例初治滤泡型淋巴瘤患者循证制定治疗方案。方法计算机检索ACP Journal Club(1991~2007.11)、Cochrane图书馆(2007年第4期)和PubMed,收集美罗华联合化疗与单纯化疗比较治疗滤泡型淋巴瘤的系统评价和随机对照试验,并对所获证据进行方法学质量评价。结果对初治滤泡型淋巴瘤患者,美罗华联合化疗优于单纯化疗。据此,笔者为患者制定了美罗华联合CVP方案,治疗4个周期后患者病情完全缓解。结论对初治滤泡型淋巴瘤患者可以选择美罗华联合化疗方案治疗。     

一例青年女性重症肌无力的循证治疗

目的:为一例青年女性重症肌无力(MG)患者制定循证治疗方案.方法:在充分评估患者病情的基础上,提出临床问题,检索Cochrane 图书馆、MEDLINE和http://www.guideline.org网站.结果:共纳入关于MG治疗方案的系统评价4篇、随机对照研究5篇及欧洲神经病学学会联盟(EFNS)2010指南1篇,...     

弥漫性大B细胞淋巴瘤预后因素分析及不同治疗方案对患者生存的影响

弥漫性大B细胞淋巴瘤(DLBCL)是非霍奇金淋巴瘤(NHL)中发病最多的亚型,占非霍奇金淋巴瘤的30%～40%[1].为进一步确定弥漫性大B细胞淋巴瘤预后因素及不同化疗方案对患者预后的影响,我们回顾性分析了143例DLBCL患者的临床资料,现报告如下.     

1例初诊老年2型糖尿病患者的循证治疗

目的借助循证医学的方法为初诊老年2型糖尿病患者确定治疗目标及治疗方案.方法在充分评估患者情况后,提出临床问题,从Cochrane图书馆(2003年第3期)、Medline(PubMed网站1990年1月～2003年2月)、和http://sumsearch uthsca edu/searchform4.htm上进行检索.检索主题词为:diabetes mellitus non-insulin-dependent; self-monitor of blood glucose; micro- and macro-vascular complications;sulphonylureas; insulin; aspirin; metformin; acarbose; self-monitor of blood glucose; older patient; hypertension management; Lipid management; RCT; human; meta-analysis;systmatic review.结果共检索出与不同问题相关的随机对照试验112篇,系统评价或Meta-分析24篇.通过对检索结果进行分析,为患者制定了合理的治疗方案.经1年随访证实,该方案适合患者.结论采用循证治疗的方法,为初治的老年2型糖尿病患者确定合理的治疗目标和治疗方案,可有效提高治疗效果.     

老年股骨颈骨折患者预防压疮的循证护理研究

目的为老年股骨颈骨折的患者制定合理的循证护理方案。方法在充分了解老年股骨颈患者病情的基础上,根据PICO原则,提出临床问题并转化为易于检索的形式,于2012年5月检索了Cochrane系统评价数据库(CDSR)、Cochrane对照试验注册中心(CCTR)、效果评论摘要数据库(DARE)、Medline、国家指南网(NGC)、PubMed网站、中国生物医学文献数据库(CBM)以及复旦大学JBI循证护理中心,获取并评价相关的系统评价、随机对照试验以及临床指南。结果共检索到3篇系统评价、2篇临床随机对照试验和1篇临床实践指南。根据检索的结果,与患者及家属沟通后,选用Braden量表对患者进行压疮评估;指导患者每2小时翻身;进行腰背肌的锻炼,2～4 h/次,第1天5遍/次,之后逐渐递增为10～20遍/次;指导摄入高能量、高蛋白食物。1周后,患者机体状况良好,顺利接受手术治疗。结论采取循证护理的方法可以为患者提供科学、个性化的护理。     

肺腺癌患者口服阿法替尼所致Ⅲ度甲沟炎的循证护理

目的为1例口服阿法替尼所致III度甲沟炎的肺腺癌患者制订合理辅助治疗的循证护理方案。方法在充分评估患者病情的基础上,根据PICO原则,提出临床问题并转换成便于检索的形式,通过检索JBI在线循证照护和治疗临床在线网络数据库JBI ConNECT+。结果最后检索出证据总结1篇,相关证据应用推荐意见1篇。根据检索结果,并结合医生的治疗方案以及患者病情和意愿,为患者制订出有效的辅助治疗护理方案。结论采用循证医学的方法为服用阿法替尼致重度甲沟炎患者制定全面的治疗护理方案可以促进甲沟炎创面的治疗和愈合,并缓解伤口带来的疼痛。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.