①供体授精:我们发现,在供体授精的效果方面,尚缺乏高质量证据.②胞浆内精子注射+体外授精:1篇系统评价发现,尚无足够的证据说明胞浆内精子注射+体外授精与单独使用体外授精何者效果更好.③宫腔内人工授精:两篇系统评价发现,宫腔内人工授精较宫颈内授精或自然性交,能明显增加每个周期的妊娠率.④体外授精与配子输卵管内移植:1个RCT显示,尚无足够证据证明体外授精与配子输卵管内移植何者效果更好.
This article reviews the progress, problems and future development of evidence-based neurology; introduces sources of clinical evidence and evidence-based recommendations on some common neurological disorders from the Quality Standards Subcommittee of the American Academy of Neurology. It promotes high quality clinical research to provide good evidence and the use of current best evidence in patient care.
Patients with early Parkinson＇s disease should be treated rationally in order to improve their quality of life and reduce the motor complications. The early employment of drugs which provides sustained central dopamine agonism and dopaminergic neuroprotection may reach this aim to some extent. Evidence of effective therapy in early Parkinson＇s disease will be introduced including： dopamine agonists, monoamine oxidase inhibitor 13, coenzymeQ10, L-dopa and a gait training.
Objective To investigate the current status of randomized controlled trials (RCTs) and clinical controlled trials (CCTs) on pressure sore in China. Methods We searched Chinese Journal of Nursing, Chinese Journal of Practical Nursing and Journal of Nurses Training in CNKI and VIP (January 2000 to December 2005) for Chinese articles on pressure sore, using "pressure sore", "bed sore", "nursing", "treatment", "prevention", "evaluation" and "management" as search terms. The retrieved articles were summarized. Results We identified 16 reports (10 RCTs and 6 CCTs). The studies were judged to be of low quality.There was one study on the evaluation, two on the prevention, and 13 on the treatment of pressure sores. Conclusion The current studies on pressure sore in China are focusing on treatment. Randomized controlled trials of large sample size of pressure sore are needed to improve nursing quality.
现有预防非妊娠期妇女膀胱炎复发的临床证据如下:①连续预防性使用抗生素:一系列随机对照试验研究表明,连续预防性使用抗生素(甲氧苄氨嘧啶、复方磺胺甲噁唑、呋喃妥英、头孢克洛或一种喹啉)6～12个月可以减少复发性膀胱炎的发生率,但各种不同用药方案间未发现感染率有差异.一个比较持续性每日使用抗生素与性交后使用抗生素的随机对照试验表明,1年后尿培养阳性率差异无统计学意义.②性交后预防性使用抗生素(复方磺胺甲噁唑、呋喃妥英或一种喹啉):4个随机对照试验研究表明,性交后2 h内使用复方磺胺甲噁唑、呋喃妥英或喹啉较安慰剂能显著降低膀胱炎发生率.一个关于性交后预防性使用抗生素和每日连续使用抗生素的随机对照试验发现,1年后二者的膀胱炎发生率的差异无统计学意义.③一次性使用复方磺胺甲噁唑:一个小样本随机对照试验发现,连续每日预防性使用复方磺胺甲噁唑与在膀胱炎症状出现后一次性使用复方磺胺甲噁唑相比,前者能显著降低膀胱炎发生率.但由于证据太有限,不能得出肯定结论.④酸果蔓汁(cranberry juice)和酸果蔓制品:一个系统评价发现,酸果蔓汁及其制品能预防复发性膀胱炎的证据不足.⑤用马尿酸乌洛托品预防:缺乏研究马尿酸乌洛托品的可靠的随机对照试验.
Objective To give an individualized treatment to a young woman with primary dysmenorrhea. Methods According to the basic principle and methods of evidence-base medicine, we searched The Cochrane Library (Issue 1, 2009), MEDLINE (PubMed, January 1950 to May 2009), ACP Journal Club (OVID, January 1991 to May 2007) for systematic reviews and randomized controlled trials (RCTs) to acquire the best clinical evidence on the treatment of primary dysmenorrhea. Results A total of 11 systematic reviews and 1 RCT were identified. A reasonable treatment plan was made through combining the patient’s will with her family members’. Conclusion The treatment effect on primary dysmenorrhea of the young woman is improved by an individualized treatment plan based on an evidence-based method.
截至2002年7月,急性心肌梗塞(acute myocardial infarction,AMI)治疗的临床证据如下:(1)改善AMI预后的证据:①血管紧张素转换酶抑制剂(ACEI):1篇概述和1个(AMI 36 h到14 d内接受治疗的患者)系统评价发现,血管紧张素转换酶抑制剂和安慰剂相比,患者30 d后的死亡率明显减少;血管紧张素转换酶抑制剂和安慰剂相比,显著增加了持续低血压和肾功能不全.血管紧张素转换酶抑制剂是提供给每一位存在AMI的患者,还是仅提供给有心衰征象的患者,目前尚无定论.②阿司匹林:1个系统评价发现,阿司匹林与安慰剂相比,能明显减少1个月时的死亡率、非致死性再梗塞以及非致死性中风.③β受体阻滞剂:2个系统评价和1个后来的RCT发现,在AMI数小时内给予β受体阻滞剂与对照比较,显著减少死亡率和再梗塞率.溶栓治疗的RCT发现,美托洛尔的及时使用与延后使用相比,明显减少患者6 d后再梗塞率以及复发的胸痛,但使用该药6 d和1年间的死亡率没有显著差异.1个研究比较了在近期有心肌梗塞并且左室射血分数小于40%,或者基本没有接受溶栓治疗的患者中使用卡维地洛与安慰剂的RCT发现,尽管单独的死亡率和复发性非致死性AMI在卡维地洛组中明显较低,但1.3年后各种原因的死亡率以及由于心血管事件住院的联合终点并没有差异.④钙离子拮抗剂:9个RCT发现,在AMI头几天范围内,二氢吡啶和维拉帕米与安慰剂相比并不降低死亡率.1个左心衰的RCT发现有限的证据表明,在AMI的头几天给予硝苯地平与安慰剂比较可能会增加死亡率.⑤糖蛋白Ⅱb/Ⅲ a拮抗剂:2个大型的RCT发现,在AMI患者中联合使用半剂溶栓剂和阿昔单抗与使用全剂量的溶栓剂相比,并没有减少1个月时的死亡率,但可预防非致死性的心血管事件;用阿昔单抗联合治疗增加了出血并发症,特别是颅外的出血.3个RCT发现,尽管加用阿昔单抗增加了出血的危险,但将阿昔单抗加到AMI患者最初的冠脉成型术或者支架中的益处仍有争议.⑥溶栓之外的硝酸盐制剂:2个溶栓时期使用硝酸盐与安慰剂的RCT发现,死亡率没有显著差异.⑦没有溶栓时的硝酸盐制剂:1个在溶栓时代前所做试验的系统评价发现,硝酸盐较安慰剂显著降低AMI患者的死亡率.⑧早期的经皮腔内冠状动脉成形术与溶栓比较(在专业中心完成):2个系统评价发现,早期的经皮腔内冠状动脉成形术与早期的溶栓相比明显降低了急性心肌梗塞患者的死亡率以及30 d的再梗塞率.在非专业中心开展的有关比较经皮腔内冠状动脉成形术与溶栓的试验结果尚不清楚.⑨溶栓:1篇研究对象为AMI患者以及最初的心电图上存在ST段上抬或者束支传导阻滞的患者的试验的概述发现,及时的溶栓治疗(症状发作后的6 h内或许到12 h或者更长)与安慰剂比较显著降低短期内的死亡率;溶栓与对照相比明显增加了中风和大出血的危险.不同类型的溶栓剂之间相互比较的RCT的Meta分析发现,死亡率没有显著差异.(2)AMI继发心源性休克的预后证据:①早期侵入性的心脏血管重建:1个以AMI 48 h内发生心源性休克患者为研究对象的RCT发现,早期侵入性的心脏血管重建与最初的单独药物治疗相比显著降低了6～12 d后的死亡率.1个样本含量较小的RCT也得出了相似的结果,但差异并不显著.②主动脉内的球囊反搏术:1个在AMI后的心源性休克患者中将主动脉内的球囊反搏术加溶栓与单用溶栓作比较的RCT摘要发现,6个月后的死亡率没有显著差异.③1个来自比较溶栓与不溶栓的RCT的AMI后心源性休克患者的亚组分析发现,21 d后的死亡率没有显著差异.④在心脏移植、早期心脏手术、正性肌力药和血管扩张剂、肺动脉插管及左心室支持系统方面,尚未发现有关这些干预措施效果的RCT证据.
截止至2002年6月,有关阑尾炎治疗的临床证据如下:①辅助性抗生素治疗:1项RCT和1项回顾性RCT发现,经阑尾切除术的复杂性和单纯性阑尾炎的成人和儿童,预防性使用抗生素可显著减少伤口感染和腹腔内脓肿.②辅助性抗生素治疗(儿童复杂性阑尾炎):1项系统评价的亚组分析发现,使用抗生素可显著减少伤口感染.③辅助性抗生素治疗(儿童单纯性阑尾炎):1项系统评价的亚组分析发现,使用抗生素不减少伤口感染.1项儿童单纯性阑尾炎的回顾性RCT发现,预防性使用抗生素不能减少伤口感染,但该RCT的样本量太小,不能排除有临床差别.④抗生素治疗和手术:1项成人疑诊阑尾炎的RCT发现,与手术治疗比较,抗生素保守治疗可减少治疗开始后12 h到10 d的疼痛和吗啡的使用.但采取抗生素保守治疗的患者有35%在1年内再次因急性阑尾炎入院,并行阑尾切除术.⑤腹腔镜手术和开腹手术(成人):1项系统评价发现,腹腔镜手术可以减少伤口的感染,减轻手术后第1天的疼痛,减少住院时间以及恢复工作的时间,但增加手术后腹腔内脓肿的发生.⑥腹腔镜手术和开腹手术(儿童):1项系统评价发现,腹腔镜手术可以减少伤口的感染,减少住院时间,但不能减轻手术后第1天的疼痛,不能减少恢复的时间和腹腔内脓肿的发生.⑦开腹手术和不治疗:无RCT证据.⑧开腹阑尾切除术中对残端的内翻处理:1项RCT发现,两次包埋和单纯结扎比较,不能减少伤口的感染、住院时间和腹腔内脓肿的发生.
To explain how to treat common gastric diseases like chronic gastritis, peptic ulcer, functional dyspepsia and gastric oesophageal reflux disease (GORD) based on evidence-based medicine. Through this paper, we try to help readers find and use clinical evidence to solve clinical problems.
Objective To find the most effective treatment for a patient with difficult selective biliary cannulation (DSBC) during endoscopic retrograde cholangiopancreatography (ERCP) by EBM practice. Methods Evidence was retrieved from The Cochrane Library (Issue 1, 2010), ACP online, NGC (1998 to June 2010), PubMed (1950 to June 2010), and CBM (1994 to June 2010). The collected evidence was then graded. Results After preliminary research, we identified 18 relevant articles. The evidence showed that pre-cutting technique could increase cannulation success rates in DSBC and was safe, effective, and time-saving for an experienced endoscopist. Pancreatic duct occupation was easier to perform than pre-cutting technique and could also increase selective cannulation success rates in DSBC. According to the evidence, together with endoscopist’s experience and the preference of the patient and his family, needle-knife precut papillotomy was performed. Successful selective biliary cannulation was accomplished after pre-cutting. Conclusion The current evidence suggests that pre-cutting technique and pancreatic duct occupation could increase selective cannulation success rates in DSBC. Patients’ condition and endoscopist’s experience should be considered properly before the operation.