基于循证医学角度的天灸临床及基础研究思路探讨

本文从循证医学的角度出发,结合目前的研究现状,就天灸的辨证论治、天灸治疗方案的确立、三伏针与三伏灸临床应用的异同、天灸与穴位敷贴的疗效比较、天灸疗法的疾病谱研究、三伏天灸与三九天灸的区别与联系等问题进行探讨。     

中国抽动障碍患者基因组学研究现状的循证评价

目的 系统评价我国抽动障碍患者(TDs)基因组学的研究现状,总结疾病易感基因和药物治疗效果相关基因,为抽动障碍疾病的防治提供循证医学证据的参考。方法 计算机检索Pubmend,Embase,Cochrane library,CBM,CNKI,VIP和万方数据库,检索时间为建库至2017年6月,纳入评价抽动疾病易感基因和药物疗效相关基因,对研究结果进行描述性分析。结果 共纳入43篇文献,涉及3 723例抽动患者和2 433个家系,年龄3~22岁。发表时间为2001-2016年。仅44.2%(19/43)纳入研究为阳性结论,共涉及24个相关基因,仅发现4个与TDs疾病相关的阳性基因,1个与药物疗效相关的阳性基因,5个与TDs合并其他疾病相关的阳性基因。结论 TDs基因组学的研究发展较快,涉及的基因呈多样化、复杂化,但研究样本量不大、有价值的阳性基因较少,缺乏从基因研究到临床转化的标准路径和方法,建议开展多中心、大样本的临床研究以探索相关基因与TDs的关联,以提供高质量的循证医学证据来指导临床实践。     

Research priorities for parenting and child health: a Delphi study

AIM: This paper is a report of a study to identify research priorities of clinical staff working with families at a Western Australian centre for parenting. BACKGROUND: Australian centres for parenting focus on children's needs while working in partnership with parents, families and their communities. These agencies incorporate primary healthcare strategies in their unique approach with families. Clinicians' research priorities at these centres have not been explored in an Australian context. METHOD: In 2005, a Delphi study was conducted in which clinicians were asked to provide a list of five important issues relating to care provided to children, parents and their families. Research topics identified were then ranked for their importance to the family and clinicians. Finally, the top 10 research topics were ranked for priority. FINDINGS: In round 1, 148 research topics were identified. Thirty-six topics were removed, due to the availability of existing evidence. Content analysis was used to collapse statements into 26 research questions, which were further classified into seven categories: parenting issues; sleep and settling issues; postnatal depression; evaluation and impact of programmes; staffing issues; centre marketing services and others. Issues relating to sleep and settling and postnatal depression were rated as top research priorities. CONCLUSION: The priorities of clinicians working with families provide research direction for this Western Australian centre and potentially other centres in Australia and similar settings elsewhere in the world. The Delphi approach in determining clinicians' perceptions of relevant research areas may be useful to direct research in other contexts.     

循证健康教育在血液透析诱导期病人中的应用

[目的]探讨血液透析诱导期病人实施循证健康教育的效果。[方法]对2003年3月～2005年12月66例病人应用循证方法通过人员培训、确定问题、查询并评价文献、临床护理实践、及时评价与反馈，在健康教育前后采用自制问卷及SF-36量表对病人健康教育效果和健康状况进行评价与分析。[结果]66例病人在健康教育前后知识掌握、行为改善方面有统计学差异（P〈0．05）；生理健康改善明显（P〈0．05），但心理健康无统计学差异（P〉0．05）；病人满意度由同期的93．5％上升到98．7％。[结论]循证健康教育能有效提高健康教育的效果和病人的参与程度。     

PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations

Analgesic protocols used to treat pain after breast surgery vary significantly. The aim of this systematic review was to evaluate the available literature on this topic and develop recommendations for optimal pain management after oncological breast surgery. A systematic review using preferred reporting items for systematic reviews and meta-analysis guidance with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Seven hundred and forty-nine studies were found, of which 53 randomised controlled trials and nine meta-analyses met the inclusion criteria and were included in this review. Quantitative analysis suggests that dexamethasone and gabapentin reduced postoperative pain. The use of paravertebral blocks also reduced postoperative pain scores, analgesia consumption and the incidence of postoperative nausea and vomiting. Intra-operative opioid requirements were documented to be lower when a pectoral nerves block was performed, which also reduced postoperative pain scores and opioid consumption. We recommend basic analgesics (i.e. paracetamol and non-steroidal anti-inflammatory drugs) administered pre-operatively or intra-operatively and continued postoperatively. In addition, pre-operative gabapentin and dexamethasone are also recommended. In major breast surgery, a regional anaesthetic technique such as paravertebral block or pectoral nerves block and/or local anaesthetic wound infiltration may be considered for additional pain relief. Paravertebral block may be continued postoperatively using catheter techniques. Opioids should be reserved as rescue analgesics in the postoperative period. Research is needed to evaluate the role of novel regional analgesic techniques such as erector spinae plane or retrolaminar plane blocks combined with basic analgesics in an enhanced recovery setting.     

肝癌术后早期下床活动方案的构建及应用

目的制订肝癌术后早期下床活动方案,探讨实施效果。方法按照入院时间将93例肝癌行肝切除术患者分为对照组45例和观察组48例。对照组实施术后常规活动护理;观察组实施早期下床活动循证实践方案,通过检索数据库获取最佳证据及整合证据,制定肝癌术后早期下床活动实践方案及流程。结果观察组术后24 h内下床活动率、首次下床时间及术后活动量指标显著优于对照组,术后排气排便时间、胃管留置时间显著短于对照组,术后24 h疼痛评分、疼痛控制满意度显著优于对照组(P0.05,P0.01);两组早期活动不良事件发生率比较,差异无统计学意义(P0.05)。结论肝癌术后早期下床活动最佳实践方案的实施,可加快肝癌患者术后康复,促进患者安全(并不增加患者安全事件)。     

糖尿病足发病风险筛查和评估的最佳证据总结

目的 总结糖尿病足发病风险筛查和评估的最佳证据。方法 检索国内外相关数据库和专业团体网站中有关糖尿病足发病风险筛查和评估的证据,包括指南、证据总结、推荐实践和系统评价。检索时限为建库至2020年1月5日。应用临床指南研究与评价系统、系统评价评估工具、JBI证据预分级及证据推荐级别系统对文献进行质量评价和证据等级评定。结果 共纳入9篇文献,包括5篇指南、1篇证据总结、1篇推荐实践和2篇系统评价。从全面采集健康史,周围神经病变的风险筛查和评估,末梢血管病变的风险筛查和评估,足部皮肤检查,足部压力的测量、足部畸形和鞋类的检查,风险分层系统的应用,风险筛查和评估的频率7个方面总结21条最佳证据。结论 最佳证据总结为临床开展规范化的糖尿病足发病风险筛查和评估提供了循证依据,医护人员应结合临床环境与患者特点,合理地应用证据。     

质子泵抑制剂临床治疗与骨折风险的循证评价

目的:基于长期和/或高剂量使用质子泵抑制剂(proton pump inhibitor,PPI)可能增加髋骨、腕骨及脊骨骨折的风险,对PPI增加骨折风险的相关研究进行综述和评价,探讨PPI增加骨折风险可能存在的机制,以更好地控制治疗的风险。方法:联网检索Pub Med、Cochrane Central、EMbase英文数据库和CNKI、CBM、VIP和Wan Fang Data中文数据库,纳入有关PPI使用与骨折关系的研究,终点结局设定为骨折,检索时间从入库截至2013年10月31日。根据希尔因果关系准则对PPI使用和骨折风险关联性进行分析,并用GRADE方法对文献质量进行评价。结果与结论:共检索得到英文文献619篇,中文文献142篇,其中包括9篇病例对照研究、6篇队列研究,以及6篇系统评价和Meta分析。关于PPI使用与骨质疏松骨折风险的临床研究均是观察性研究,研究的结果显示PPI长期使用可增加导致髋骨、腕骨、脊骨骨折的危险性,但是关联性并不是很强,高剂量、长疗程有更高的骨折风险。系统评价和Meta分析合并的OR值也都小于2,研究之间存在较大的异质性,按GRADE方法对纳入研究质量评价为极低质量证据。有待于更多高质量的循证证据来进一步评估发生骨折不良反应的风险。对于长期使用PPI的患者宜选择最小维持剂量,考虑间歇用药,或换用H2受体拮抗剂(H2RA)。