Objective To summarize the available clinical research evidence for the treatment of hepatorenal syndrome (HRS). Methods Using the basic methods and principles of evidence-based medicine, we searched and evaluated clinical studies involving the treatment of HRS. Results We found that plasma expansion, vasoconstrictor, transjugular intrahepatic portosystemic shunts (TIPS) and liver transplantation were effective interventions for patients with HRS. Conclusion HRS is a common complication of end-stage liver diseases and the prognosis for patients with HRS is extremely poor. However, due to the small number of clinical trials, small sample sizes and low methodological quality, the strength of the current evidence is limited. Rigorously-designed, randomized, multi-center, large-scale trials on HRS are required.
Cirrhosis is an end stage of condition of various liver diseases with specific clinic and pathologic process. The incidence is high and it seriously affects the quality of life for patients. In order to obtain the best prevention and treatment for end-stage cirrhosis, we searched The Cochrane Library (Issue 3, 2004), SUMsearch (1981~2004) and MEDLINE (1981~2004), and identified 15 systematic reviews and 65 randomized controlled trials. We critically assessed the quality of studies. The results showed the principal treatment of cirrhosis was to deal with complications, such as the prevention and treatment of variceal bleeding, the treatment of ascites etc.
Objective To identify evidence-based treatment choices for a patient with increased intracranial pressure after acute traumatic brain injury. Methods We searched The Cochrane Library (Issue 2, 2006), MEDLNE (1981 to August 2006) and CBMdisc (1978 to August 2006) to identity systematic reviews (SRs), randomized controlled trials (RCTs), controlled clinical trials (CCTs) and prospective cohort studies involving the efficacy and safety of pharmacotherapy and non-pharmacotherapy for increased intracranial pressure after acute traumatic brain injury. Results We found 2 SRs and 8 RCTs on pharmacotherapy, and 6 SRs and 2 RCTs on non-pharmacotherapy. Conventional-dose mannitol was no better than hypertonic saline, but was better than other intracranial pressure lowering agents. High-dose mannitol can reduce mortality and the incidence of severe disability compared with conventional-dose mannitol. There were no studies comparing high-dose mannitol and hypertonic saline. Non-pharmacotherapy was not recommended for routine use due to the lack of good quality evidence. Conclusion For patients with increased intracranial pressure after acute traumatic brain injury, mannitol is effective in reducing the mortality and the incidence of severe disability. However, more large-scale RCTs are required to compare high-dose mannitol versus other drugs. Non-pharmacotherapy is not recommended as an adjunct therapy at present.
Objective To formulate an evidence-based treatment for a patient newly diagnosed with follicular lymphoma. Methods Based on the clinical questions we raised, evidence including systematic reviews and randomized controlled trials was collected from ACP Journal Club (1991 to November 2007), The Cochrane Library (Issue 4, 2007) and PubMed. The retrieved studies were further critically appraised. Results The addition of rituximab to chemotherapy (R-chemo) was superior to chemotherapy alone in patients with follicular lymphoma. The regimen of CVP chemotherapy plus rituximab (R-CVP) was administered to the patient. After 4 courses of R-CVP, the patient had a complete response (CR). Conclusion In newly diagnosed patients with follicular lymphoma, R-chemo is an effective treatment regimen.
Lung cancer is an epithelial cancer arising from the bronchial surface epithelium or bronchial mucous glands. Non-small lung cancer constitutes about 75%-80% of all lung cancer. At the time of diagnosis, a lot of people have got stage Ⅲb non-small lung cancer which is unresectalbe. Both chemotherapy and radiotherapy are widely used in unresectable stage Ⅲ non-small lung cancer. The regimes of chemotherapy or radiotherapy are varied too. Systematic reviews and randomized controlled trials have provide much convincing evidence for us to choose and utilize the most appropriate treatment.
Objective To make an individualized administration scheme via evidence-based medicine methods, namely adding heparin into the total nutrient admixture (TNA) solution, so as to help a neonate to prevent the occlusion of peripherally inserted central catheter (PICC). Methods After carefully assessing the condition of neonate, this clinical issue was put forward in accordance with the PICO principles. Randomized controlled trials (RCTs) and systematic reviews on neonates’ PICC occlusion were collected from The Cochrane Library, CCTR, DARE, NGC, MEDLINE (Ovid) and CBM from inception to 2011. The clinical intervention scheme was finally made after the assessment of the retrieved evidence and neonate’s physiological condition. Results A total of 4 RCTs and 1 systematic review related to the issues were identified. The following scheme was finally made for the neonate through the assessment of the retrieved evidence and combination of intentions of the patient’s family members: heparin (0.5 U/mL) was added into TNA to prevent PICC occlusion. During the application, blood routine test and blood coagulation were monitored, and the catheter opening time and extubation reason were recorded. Through the above treatment, the neonate successfully completed the treatment before extubation. The time of both PICC detaining and opening was 20 days in total, and there were no PICC occlusion, no catheter thrombosis, and no catheter related bloodstream infection. Moreover, no observation showed thrombopenia and aggravated coagulation disorders resulted from heparin. Conclusion The evidence-based medicine method is an effective way to make reasonable heparin scheme for neonate, so as to prevent PICC occlusion, reduce catheter thrombosis, decrease risks of catheter related blood circulation infection, assure successful completion of treatment, and guarantee the safety of patients.
Objective To make an evidence-based treatment plan for a smoker with periimplantitis. Methods Based on the clinical problems raised from the case, we searched The Cochrane Library (Issue 2, 2009), ACP Journal Club (1991 to July 2009), MEDLINE (1950 to July 2009), EMbase (1980 to July 2009) and Chinese Journal Fulltext Database (1994 to July 2009) for guidelines, systematic reviews, meta-analyses and randomized controlled trials (RCTs). The quality of the included studies was assessed. Results A total of 4 systematic reviews, 8 RCTs were included. The following methods were supported by Level A evidence: (1) Scaling combined with local antibiotics; (2) Guided bone regeneration; (3) Non-surgical debridement with titanium hand-instruments or with an ultrasonic device. Based on the available evidence, we proposed a three-stage therapy plan for the patient: In the first stage, full mouth ultrasonic scaling was performed. The peri-implant pocket was debrided with plastic curettes, and then minocycline gel was applied once a week for four times. The patient was persuaded to maintain oral hygiene and quit smoking. In the second stage, four weeks later, open flap debridement and guided bone regeneration were conducted. In the third stage, long-term care of oral hygiene and dental implants were performed. After 6 months of follow-up, the peri-implant tissues were healthy with no evidence of inflammation, bleeding or suppuration. Conclusion Based on the approach of evidence-based medicine, we accomplished the treatment of the case with reliable outcomes.
Objective To formulate an evidence-based treatment plan for a patient with advanced hepatocellular carcinoma. Methods The clinical problems were put forward after full evaluation of patient’s conditions, and then the evidence related to the diagnosis and treatment of primary hepatocellular carcinoma was collected from The Cochrane Library (Issue 4, 2010), PubMed (1980 to 2010), Embase (1990 to 2010) and Wanfang Data (1990 to 2010). All the collected evidence was critically assessed. Both patient preferences and physician clinical experience were also taken into consideration in the decision-making treatment. Results A total of 153 relevant literatures were detected, and 13 meta-analyses or systematic reviews, 23 RCTs and 4 practice guidelines were identified. A rational treatment plan was made upon a serious evaluation of the data and the opinion of the patient. After a 6-month follow-up, the plan proved to be optimal. Conclusion The individualized treatment plan according to evidence-based methods for patients with advanced hepatocellular carcinoma can effectively improve the therapeutic efficacy and the life quality.
Objective To find individualized evidence-based treatments for a patient with lower rectal cancer. Methods Based on the clinical questions raised, evidence was collected and critically assessed. Patient preferences and physician clinical experience were also taken into consideration in the decision-making treatment. Results Twenty-four systematic reviews or meta analyses and 1 clinical guideline were included. The evidence showed that preoperative chemoradio- therapy reduces risk of local recurrence and death from rectal cancer compared to preoperative radiotherapy alone. Preoperative combined chemoradiotherapy, enhanced pathological response and improved local control in the resectable stage II and III rectal cancer. Preoperative chemoradiotherapy reduced the risk of local recurrence as compared with postoperative chemoradiotherapy. Postoperative radiotherapy alone did not improve survival for the patients with resected stage II and stage III rectal cancer, whereas either chemotherapy alone or combined chemotherapy and radiotherapy improved survival in comparison with observation. As compared with conventional radical surgery, total mesorectum excision (TME) resulted in lower postoperative local recurrence rate and higher survival rate. No significant differences in terms of disease-free survival rate, local recurrence rate, mortality, and morbidity were found between laparoscopic and open total mesorectal excision. Conclusion The patients with lower rectal cancer might benefit from preoperative chemoradiotherapy, postoperative chemotherapy, and chemoradiotherapy. TME is the standard rectal cancer surgery. However, long-term prognostic benefits need to be confirmed by further follow-up.