INTRODUCTION

Ten trials13,15,19,24,25,27,29,32,35,37involving 654 participants provided data on systolic pressure.Compared with conventional treatment alone,Shenmai injection plus conventional medicine significantly increased systolic pressure(WMD10.58,95%CI6.70 to 14.45;heterogeneity test:I2=79%,P＜0.01;random-effect model).Six trials13,19,24,25,29,35and four trials26,30,36,41respectively reported that Shenmai injection increased diastolic pressure(WMD6.05,95%CI4.42 to 7.68;heterogeneity test:I2=1%,P=0.41;fixed-effect model)and mean arterial pressure(WMD11.14,95%CI8.08 to 14.21;heterogeneity test:I2=31%,P=0.23;fixed-effect model;Table 2).

Several trials have shown that Shenmai injection might have therapeutic potential for patients with shock.Nevertheless,the quality of these studies,as well as the efficacy and safety of Shenmai injection,has not been evaluated systematically,which is valuable for clinical practice and required for TCM to receive approval in international medical fields.Therefore,we conducted this Meta-analysis to assess the benefits and adverse effects of Shenmai injection plus conventional medicine treatment versus conventional medicine for the treatment of shock in adult patients.

我们本该明白教育应做什么：智育是要发展好奇心和理性思考的能力，而不是灌输知识；德育是要鼓励崇高的精神追求，而不是鼓吹规范；美育是要培育丰富的灵魂，而不是传授技艺。

METHODS

Eligibility criteria

Types of study design:randomized controlled trials(RCTs)to evaluate Shenmai injection for shock,irrespective of allocation concealment and blinding status were included in this analysis.The trials using randomization methods(either clear description or unclear description),are included.

In conclusion,our results suggest that Shenmai injection plus conventional medicine treatment was more beneficial than conventional medicine alone for patients with shock.It could increase the total effective rate,decrease mortality rate and improve clinical symptoms(blood pressure,urine output and heart rate).For cardiogenic shock,Shenmai injection improved cardiac function(Killip classification and LVEF).However,our findings should be interpreted cautiously due to the potential bias and the methodological quality of included trials.

Types of participants:the trials included participants regardless of gender,age and ethnic group.In each included trial,shock was clearly diagnosed according to the guideline7developed in 2006,and each type of shock was considered,such as septic shock,cardiogenic shock,hypovolemic shock,neurogenic shock and/or anaphylactic shock.

Types of interventions:shenmai injections plus conventional medicine treatment was compared with conventional medicine alone.Shenmai was defined in this review as the products derived from Renshen(Radix Ginseng)and Maidong(Radix Ophiopogonis Japonici).Trials were included regardless of dosage and duration of treatment.

Types of outcome measures:the primary outcome measures included total effective rate and mortality rate.The secondary outcome measures included heart rate,blood pressure,urine volume,Killip classification and left ventricular ejection fraction(LVEF).The number and type of adverse events in each study were also noted.The criteria for clinical effect were based on "Consensus on circulatory shock and hemodynamic monitoring",8which was developed by the European Society of Intensive Care Medicine.The total effective rate=number of patients who respond to the therapy effectively/total number of patients×100%.Effectiveness was defined as recovery of symptoms and signs of shock after the therapy.

Search strategy

We systematically searched the following electronic databases from each database's inception to May 2015:PubMed,the Cochrane Library,EBSCO-MEDLINE Complete,BIOSIS,BioMed Central,Web of Knowledge;and four Chinese databases:China National Knowledge Infrastructure Database(CNKI),VIP Journal Integration Platform,Wanfang Database and Chinese Biomedical Literature Database.Different search strategies were combined as follows:for English databases,such as PubMed,the search terms included("Shenmai"[Title/Abstract]OR"Shen-mai"[Title/Abstract]OR"Shen mai"[Title/Abstract]OR"Panax and Ophiopogon"[Title/Abstract])AND("shock"[MeSH terms]);for Chinese databases,such as CNKI,the search terms included("Shenmai"[Abstract]OR"Renshen and Maidong"[Abstract])AND("Xiu Ke"[Subject]).The specific search procedure varied in some cases according to the different interface settings of each database.No language restrictions were applied.We also searched references in published articles,reviews and relevant articles.Finally,we searched the websites of grey literature(http://www.opengrey.eu/,http://www.greylit.org/home)to include unpublished studies.

The search strategy for PubMed is as follows:

#1"Shenmai"[Title/Abstract]

#2"Shen-mai"[Title/Abstract]

#3"Shen mai"[Title/Abstract]

The methodological quality of all the trials was just passable,due to the lack of some necessary information in these articles.Twenty four trials stated the use of random assignment,but had insufficient information to judge whether or not the randomization was properly conducted.Furthermore,it was unclear whether the majority of included trials performed allocation concealment and blind methods.Some trials also failed to report the frequency of adverse events.Thus the results of our study should be interpreted cautiously due to the methodology and potential bias.The quality of trials of TCM needs to be improved urgently.49For further clinical trials,more emphasis should be paid on the methodological quality,especially for the design of trials,generation of allocation sequence,allocation concealment,double blinding,sample size determination,etcetera.Meanwhile,more widespread trials should be performed,including studies with a diverse ethnic and geographic population.If significantly beneficial effects of Shenmai injection for shock are confirmed in methodologically rigorous trials,Shenmai will be an important contribution of TCM to human health care worldwide.

#5"Shock"[MeSH terms]

1.2.1 外在病耻感和内在病耻感：Goffman[5]将病耻感分为外在病耻感和内在病耻感。外在病耻感是指患者因为某些疾病的特征遭受来自公众负面态度所致的歧视体验；内在病耻感是指在经历来自公众的“污名化”后，对公众歧视的预见感受或者将公众歧视转化为自身的羞愧感受，患者已经认可来自社会的刻板印象和偏见，甚至出现自我歧视。研究发现内在病耻感比外在病耻感更常见，且内在病耻感就是心理困扰和生活质量问题的来源，全面评估帕金森病患者的病耻感需要综合评估帕金森病患者的内在病耻感和外在病耻感[4]。

#6#1 OR#2 OR#3 OR#4

#7#6 AND#5

Study selection and data extraction

Two researchers screened the titles,abstracts and the full texts independently using a standardized screening guide.Initially,abstracts were screened to exclude obviously ineligible reports then the full texts were reviewed for all the remaining studies.Any disagreement was resolved by discussion.Characteristics and information of each included study was obtained for further description,quality assessment and data analysis.

Study quality assessment

The methodological quality of each trial was assessed according to the criteria from"Cochrane handbook for systematic reviews of interventions".9The items included random sequence generation(selection bias),allocation concealment(selection bias),blinding of participants and personnel(performance bias),blinding of outcome assessment(detection bias),incomplete outcome data(attrition bias),selective reporting(reporting bias)and other bias.For each item,there were three alternative grades of risk:low risk of bias,unclear and high risk of bias.When inadequate information was presented in the article or we were unable to explicitly judge"high"or"low",the item was judged as"unclear".Two researchers independently completed and mutually checked the allocated grades.Disagreements were resolved by discussion or consensus as mediated by a third reviewer.

Data analysis

Review Manager 5.3(The Nordic Cochrane Centre,The Cochrane Collaboration,Copenhagen)and Stata 12.0(Stata Corp.,LP,College Station,TX,USA)were used to analyze the data.Dichotomous data were presented as risk ratio(RR)or risk difference(RD),while continuous outcomes were expressed as weighted mean difference(WMD),all with 95%confidence intervals(CIs).The statistical test of heterogeneity was performed to evaluate the heterogeneity using theI2statistics.A fixed-effect model was applied except in cases where heterogeneity was significant(P＜0.05),in which case a random-effect model was applied.10Subgroup analyses were conducted by the participants'type of shock.We also conducted a sensitivity analysis to investigate the influence of a single trial on the overall effect estimate by omitting one trial in each turn.Funnel plot analysis was utilized to investigate potential publication bias.The Duval and Tweedie non-parametric"trim and fill"method11were used to estimate the"unbiased"effect if necessary.

RESULTS

Search results

The initial search identified 999 potentially relevant articles,which were all published studies.Totally 556 studies were obtained after duplicate records were deleted.After screening titles,abstracts and full texts,30 trials were included in this Meta-analysis(Figure 1).All included trials were published in Chinese.

Study characteristics

Thirty trials12-41involving a total of 2038 participants(1038 in the experimental groups)were included in the present Meta-analysis(Table 1).The sample sizes ranged from 23 to 138.Nineteen trials12,17-20,23,24,26,27,30,32-40reported the gender of participants,with the proportion of males ranging from 50.0%to 79.1%.Eighteen trials12,15,17,19,20,23,24,26,27,30,32,33,35-40reported the mean age of participants:from 31.1 to 67.0 years.Eight trials14,15,17,20,26,30,35,39included participants with several type of shock,while three,12,27,36five13,16,24,25,41and fourteen18,19,21-23,28,29,31-34,37,38,40trials only included participants with septic shock,cardiogenic shock and hypovolemic shock respectively.Shenmai injection was administered as intravenous injection or/and infusion in all included trials.The dosage of Shenmai injection varied across studies from 10 to 480 mL.Twenty trials12,13,16,17,20,21,23,25,27,30-33,35-41mentioned the duration of treatment,which varied from 1 to 14 d.The details of co-interventions(conventional medicine treatment)of the included trials are provided in supplementary material.

Study quality

All included trials indicated randomization,with six of the trials14,26,30,35,36,41reporting that the random sequence was generated by a random digits table.None of the trials mentioned whether they used allocation concealment.Only two of them14,25reported the use of blinding.All of the included studies appeared to have ade-quate and acceptable compliance.In general,the methodological quality of the included trials was passable,and more details of the trials are presented in Figure 2.

Figure 1 Flow diagram of studies identification RCTs:randomized controlled trials.

Table 1 Characteristics of the included trials

?

Table 1 Characteristics of the included trials(continuted)

Notes: E: experiment group; C: control group; NM: not mentioned; SD: standard deviation; SS: septic shock; CS: cardiogenic shock; HS: hypovolemic shock; NS: neurogenic shock; AS: anaphylactic shock;GS: glucose solution; q.d.: once a day; b.i.d.: twice a day; q3h: once every three hours; st: immediately. aIf Shenmai injection was used with glucose solution, the treatment was conducted by intravenous infusion.Otherwise, it was conducted by intravenous injection.

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Total effective rate

Total effective rate was the most commonly used outcome measure to evaluate efficacy.Eighteen trials12,14,15,17,18,20-23,28-31,33,34,38-40involving 1309 participants provided data on total effective rate.This outcome measure was defined as improvements of the signs and symptoms of shock in these trials,and no clinical heterogeneity was found(heterogeneity test:I236%,P=0.06).Compared with conventional medicine treatment alone,Shenmai injection plus conventional medicine significantly increased the total effective rate(RR1.25,95%CI1.18 to 1.31;fixed-effect model;Figures 3).Subgroup analysis showed the similar effect in trials including participants with septic shock only(RR2.01,95%CI1.15 to 3.50;1 trial),in trials including participants with hypovolemic shock only(RR1.26,95%CI1.18 to 1.35;11 trials),and in trails including participants with several type of shock(RR1.18,95%CI1.09 to 1.28;6 trials).

Mortality rate

Six trials13,15,16,19,25,40involving 275 participants with data on mortality rate indicated that Shenmai injection plus conventional medicine treatment was better than conventional medicine treatment alone(RD－0.10,95%CI－0.17 to－0.02;heterogeneity test:I230%,P=0.21;fixed-effect model;Figure 4).Subgroup analysis showed the similar effect in trials including participants with cardiogenic shock only(RD－0.14,95%CI－0.26 to－0.01;3 trials),but no significant effect in trails including participants with hypovolemic shock only(RD－0.02,95%CI0.10 to 0.05;2 trials)and in trials including participants with several type of shock(RD－0.13,95%CI－0.35 to 0.10;1 trial).

Figure 2 Risk of bias summary:review authors'judgments about each risk of bias item for each included study

Heart rate

Fourteen trials15,19,24-27,29,30,32,35-37,39,41involving 947 participants provided data on heart rate.Compared with conventional medicine treatment alone,Shenmai injection plus conventional medicine significantly decreased heart rate(WMD－13.41,95%CI－16.39 to－10.42;heterogeneity test:I280%,P＜0.01;random-effect model;Table 2).Subgroup analysis showed the similar effect in trials including participants with septic shock only(WMD－17.69,95%CI－21.89 to－13.48;2 trials),in trials including participants with cardiogenic shock only(WMD－13.31,95%CI－19.98 to－6.65;3 trials),in trials including participants with hypovolemic shock only(WMD－11.23,95%CI－18.91 to－3.55;4 trials),and in trails including participants with several type of shock(WMD－13.19,95%CI－17.87 to－8.51;5 trials).

(4)重复步骤(2)和步骤(3)直到达到预设层数(理论上层数越多结果越精确,不过计算量和运算时间也会增大),将最后一层的最小距离误差分段的中点认为目标的空间位置。

Blood pressure

Shock is a life-threatening,generalized form of acute circulatory failure associated with inadequate oxygen utilization by the cells.1,2It was reported that up to one-third of patients admitted to the intensive care unit were in shock.3Shock can result in multiorgan failure and a high mortality rate,making immediate intervention necessary.4Traditional Chinese Medicine(TCM)has been believed with potential effects for treating shock.In China,Shenmai,a kind of traditional Chinese herbal medicine,is usually used as a comple-mentary treatment to recommended western treatments for shock.5It is a mixture of two herbal components:Renshen(Radix Ginseng)and Maidong(Radix Ophiopogonis Japonici).6These herbs are combined but there is no standard proportion for each herb.There are commonly four forms of Shenmai,including capsule,powder,oral liquid and injection.

Urine volume

Five trials12,27,32,36,37involving 417 participants provided data on urine volume.Compared with conventional medicine treatment alone,Shenmai injection plus conventional medicine significantly increased urine volume(WMD18.49,95%CI3.32 to 33.66;heterogeneity test:I299%,P＜0.01;random-effect model;Table 2).Subgroup analysis showed the similar effect in trials including participants with hypovolemic shock only(WMD19.79,95%CI17.59 to 21.94;2 trials),but no significant effect in trails including participants with septic shock only(WMD19.05,95%CI－6.88 to 44.97;3 trials).

1.4 统计学方法 采用SPSS 22.0软件处理，计数资料以（%）表示采用 χ2检验，计量资料以（）表示采用独立样本t检验，P＜0.05为差异有统计学意义。

大面积烧伤后的创面表面为新鲜的肉芽组织,经过细菌培养其阳性率较高,在创面的愈合过程中,需采用良好的抗菌及良好的修复创面药物,使创面表面细菌含量减少,促进创面能够有效向中心方向愈合[4]。磺胺嘧啶银锌霜就能起到杀菌抑菌、抗感染及促进上皮生长的多重疗效。磺胺嘧啶银锌霜中含有的SD-AG具有较强的杀菌作用,其中含有的锌离子(SD-Zn)除了具有杀菌作用外,还兼顾着修复创面的独特优势。因此,将磺胺嘧啶银锌霜涂抹在患者烧伤创面上,能够在创面上形成一层抗菌屏障,避免外界环境细菌的侵入,同时SD-Zn可通过与机体去氧核糖核酸的结合,抑制细菌的繁殖,不仅具有良好的抗菌作用,同时还能起到修复创面的功效[5]。

Killip classification and LVEF

Three trials13,16,25involving 132 participants with cardiogenic shock selected as outcome measure an improvement of at least one class on the Killip classification.These trials indicated that Shenmai injection in combination with conventional medicine was significantly superior to conventional medicine treatment alone for Killip classification of patients with cardiogenic shock(RR1.42,95%CI1.12 to 1.80;hetero-geneity test:I20%,P=0.86;fixed-effect model;Table 2).

Data were available from three trials13,25,41involving 89 participants with cardiogenic shock on LVEF,the ratio of the stroke volume and the left ventricular end-diastolic volume,which is frequently used for the assessment of cardiac function.Compared with conventional medicine treatment alone,Shenmai injection plus conventional medicine significantly increased LVEF of patients with cardiogenic shock(WMD7.59,95%CI4.32 to 10.85;heterogeneity test:I20%,P=0.37;fixed-effect model;Table 2).

4.2 1961-2017年期间，天峻地区干旱经历了湿—干—湿—干—湿的变化，其中，20世纪60年代初期至70年代初期、80年代中期至90年代中期、21世纪00年代末期至10年代中期对应的是相对湿润的时间段，而70年代初期至80年代中期、90年代中期至21世纪00年代末期对应的是相对干旱的时间段。M-K检验结果表明，干湿突变年为1966年。

Sensitivity analysis

We deleted one single study from the overall pooled analysis each time to check the influence of the removed data set to the overall effects.After the deletion of anyone of the trials with total effective rate used as outcome measure,the association still kept significant(Figure 5).

Adverse effects

Three trials13,24,27(10%)reported mild adverse events,including dizziness,palpitation and flushing of the skin.Two trials25,38(6.67%)reported that no adverse effects were observed until the end of treatment,while the remaining twenty-five trials12,14-23,26,28-37,39-41(83.3%)did not mention whether adverse events occurred.

Publication bias

The shape of funnel plot was asymmetrical indicating that potential publication bias might influence the results of this review(Figure 6).Therefore,the Duval and Tweedie non-parametric"trim and fill"method was conducted to adjust for potential publication bias.Meta-analysis with the"trim and fill"method did not result in different conclusion(RR1.18,95%CI1.08 to 1.22),which supported the robustness of our results.

DISCUSSION

Figure 3 Forest plot of comparison:Shenmai injection plus conventional medicine treatment versus conventional medicine treatment,outcome:total effective rate

RR:risk ratio;M-H:Mantel-Haenszel;CI:confidence interval.

Figure 4 Forest plot of comparison:Shenmai injection plus conventional medicine treatment versus conventional medicine treatment,outcome:mortality rate

RD:risk difference;M-H:Mantel-Haenszel;CI:confidence interval.

There have been some reviews supporting the effectiveness of Shenmai injection for shock,heart failure,acute myocardial infarction,viral myocarditis and tumor chemotherapy.42-45However,none of them combine the results from multiple trials to systematically evaluate the efficacy and safety of Shenmai injection for shock.Consequently,this Meta-analysis investigated the impact of Shenmai injection combined with conventional medicine treatment.Our results suggested that Shenmai injection plus conventional medicine increased the total effective rate and decreased the mortality rate.The definition of the effective rate was consistent in each included study.Furthermore,the clinical signs of shock typically include low blood pressure,low or no urine output,and a rapid and weak pulse.8Therefore,blood pressure,urine output and heart rate are dynamically monitored in a patient who is suspected to be suffering from shock.Our Meta-analysis found that Shenmai injection plus conventional medicine treatment was superior to conventional medicine alone in increasing blood pressure and urine output,and decreasing heart rate.Moreover,the evaluation of cardiac output and cardiac function can be helpful in evaluating the impact of therapeutic interventions.8Shenmai injection was also found to ameliorate Killip classification and the left ventricular systolic dysfunction in patients with cardiogenic shock.

In all included trials,only five reported information on adverse effects.Three trials reported mild adverse effects,and two trial reported no adverse effects.Unfortunately,other twenty-five trials did not report any information on adverse effects.Possible explanations for the lack of reporting adverse effects in these trials include:(a)adverse effects were not recorded;(b)no adverse effects happened,but researchers failed to report the lack of adverse events;(c)mild adverse effects occurred and were attributed to concomitant aspects of the injury or diseases.Hence,we could not exclude potential or long term adverse effects.Current researches also showed that some potential factors such as irrational compatibility,dosage and individual factors of patients may lead to adverse drug reactions occurrence.46,47This study was conducted according to the PRISMA statement,with comprehensive literature search and rigorous methodological quality assessment.Nonetheless,there are several limitations including the following aspects:

2.切实贯彻群众路线是做好调查研究工作的重要保证。全党在调查研究中注重收集群众的意见和诉求，据此制定方针、政策和办法，然后征求群众的意见，以便作出进一步修正，因此，此次调查研究切实贯彻了党的群众路线。

Although comprehensive search was performed to avoid language as well as location bias,all the trials included were only in Chinese.In China,most people believe Traditional Chinese Medicine is effective in treatment of many diseases with few adverse effects.Chinese herbs and medicine are regularly used in most hospitals in China.However,few trials on the efficacy and safety of Shenmai for shock have been conducted outside China and published in English.Furthermore,since most of published trials reported positive findings,48the trials with negative findings potentially have not been published.As a consequence,we could not exclude potential publication bias though no related article was identified in grey literature search.Fortunately,the result of"trim and fill"method showed no significant difference,in-dicating the publication bias may not influence our results substantially.

Table 2 Summary of effect estimates of the included trials with secondary outcome measures

Notes:SS:participants with septic shock only;CS:participants with cardiogenic shock only;HS:participants with hypovolemic shock only;STS:participants with several type of shock;RR:risk ratio;WMD:weighted mean difference;CI:confidence interval.ainclude participants with cardiogenic shock only.

Outcome or subgroup title Heart rate HS CS SS STS Systolic pressure HS CS SS STS Diastolic pressure HS CS STS Mean arterial pressure CS SS STS Urine volume HS SS Killip classificationaLVEFaNo.of studies 14 No.of participants 947 326 110 210 301 654 326 115 138 75 288 150 115 23 223 25 72 126 417 176 241 132 89 Effect estimates Heterogeneity 4 3 2 5 1 0 4 3 1 2 6 2 3 1 4 1 1 2 5 2 3 3 3 Statistical methodWMD,randomWMD,randomWMD,randomWMD,randomWMD,randomWMD,randomWMD,randomWMD,randomWMD,randomWMD,randomWMD,fixedWMD,fixedWMD,fixedWMD,fixedWMD,fixedWMD,fixedWMD,fixedWMD,fixedWMD,randomWMD,randomWMD,randomRR,fixedWMD,fixed Effect size(95%CI)－13.41(－16.39,－10.42)－11.23(－18.91,－3.55)－13.31(－19.98,－6.65)－17.69(－21.89,－13.48)－13.19(－17.87,－8.51)10.58(6.70,14.45)10.73(5.79,15.66)11.40(－1.71,24.50)17.00(13.00,21.00)3.65(－6.27,13.57)6.05(4.42,7.68)5.73(3.79,7.66)7.06(3.86,10.26)5.00(－4.71,14.71)11.14(8.08,14.21)9.00(1.15,16.85)18.04(10.74,25.34)9.82(6.08,13.56)18.49(3.32,33.66)19.76(17.59,21.94)19.05(－6.88,44.97)1.42(1.12,1.80)7.59(4.32,10.85)Pvalue＜0.01＜0.01＜0.01＜0.01＜0.01＜0.01＜0.01 0.09＜0.01 0.47＜0.01＜0.01＜0.01 0.31＜0.01 0.02＜0.01＜0.01 0.02＜0.01 0.15＜0.01＜0.01I2(%)80 92 0 46 79 79 79 79-47 1 0 5 6 - 3 1 - - 0 9Pvalue＜0.01＜0.01 0.83 0.17＜0.01＜0.01＜0.01＜0.01-0.17 0.41 0.95 0.11-0.23- -9 0 9 9 0 0 0.69＜0.01 0.63＜0.01 0.86 0.37

There was no statistical heterogeneity in trials with primary outcome measures.However,heterogeneity was identified in trials with some secondary outcome measures.Shenmai injection was made from several different manufacturers,so the nature of the preparation and the proportion of each constituent herb might be different.The dosage varied across studies from 10 to 480 mL per day,and the duration of treatment varied from 1 to 14 d.We planned to perform subgroup analyses for these confounding factors,but did not do this because of the small number of studies in each subgroup.Therefore,we could not exclude the confounding bias.

#4"Panax and Ophiopogon"[Title/Abstract]

Figure 5 Sensitivity analysis showingRRand 95%CIby omitting each trial from the included trials of total effective rateRR:risk ratio;CI:confidence interval.

Figure 6 Funnel plot of publication bias

RRis plotted versus standard error of LogRRfor the included trials with total effective rate used as outcome measure.SE:standard error;RR:risk ratio.

冬日的荷塘，自然是不会有田田的叶子的。仅剩的几片“顽强”叶子也早在秋·日就变得枯黄，如同戴着逍遥巾的独脚鬼。

ACKNOWLEDGMENTS

We wish to thank Liu Hui(Zhejiang University,China)and Guo Jing(Zhejiang University,China)for their kind help and suggestions with this manuscript.

REFERENCES

1 Weil MH,Henning RJ.New concepts in the diagnosis and fluid treatment of circulatory shock.Thirteenth annual becton,dickinson and company oscar schwidetsky memorial lecture.Anesth Analg 1979;2(58):124-132.

©2018 JTCM.All rights reserved.

3 Sakr Y,Reinhart K,Vincent JL,et al.Does dopamine administration in shock influence outcome?Results of the sepsis occurrence in acutelyⅢpatients(SOAP)study.Crit Care Med 2006;3(34):589-597.

4 Houston MC.Diagnosis and treatment of shock.South Med J 1980;4(73):477-484.

5 Li YX,Lan RQ.Progress of shenmai injection for shock in clinical practice.You Jiang Yi Xue 2007;5(35):589-591.

可隔离直流故障的直流电网用DC/DC变换器拓扑//朱思丞,赵成勇,李帅,李承昱,许建中//(7):108

6 Li JS,Wang HF,Li SY,Yu XQ,Wang ZW.Shenmai injection for chronic pulmonary heart disease:a systematic review and Meta-analysis.J Altern Complement Med 2011;7(17):579-587.

7 Antonelli M,Levy M,Andrews PJ,et al.Hemodynamic monitoring in shock and implications for management.International Consensus Conference,Paris,France,27-28 April 2006.Intensive Care Med 2007;4(33):575-590.

8 Cecconi M,De Backer D,Antonelli M,et al.Consensus on circulatory shock and hemodynamic monitoring.Task force of the European Society of Intensive Care Medicine.Intensive Care Med 2014;12(40):1795-1815.

9 Higgins JP,Green S(editors).Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0(updated March 2011).The Cochrane Collaboration,2011.Available from www.cochrane-handbook.org.

10 Petitti DB.Approaches to heterogeneity in Meta-analysis.Stat Med 2001;23(20):3625-3633.

所有统计计算均用SASv 9.13统计分析软件进行。定量数据采用t检验、ANOVA或Wilcoxon秩和检验。定性数据用χ2检验、Fisher精确概率、连续校正χ2检验、或Wilcoxon秩和检验，考虑到中心或其他因素的影响采用CMHχ2检验。对于生存数据采用，Log‐rank检验。主要指标的两两比较，采用95%置信区间（95%CI）法，计算双侧95%CI。全部的假设检验均采用双侧检验，取α=0.05。

11 Duval S,Tweedie R.A nonparametric"trim and fill"method of accounting for publication bias in Meta-analysis.J Am Stat Assoc 2000;449(95):89-98.

为了从根本上实现社会人才供需总量的平衡发展，继续医学教育管理的招生规模要和实际的就业率进行适度的挂钩。各个专业的供需数量之间的平衡状态对于毕业生的就业专业特征以及市场的人才分割具有决定性的作用，只有两者之间尽可能地保持一致，才有可能避免出现专业性方面的供需不平衡问题。在就业的市场化运行机制的模式下，高校设置的专业以及专业招生的数量，最终都是会进入到社会中并受到制约，就业率就是反映供需状况的重要指标之一。把专业招生规模与实际的就业率进行挂钩，适当进行结构上的调整，这样对于人才继续医学教育管理具有实质性的积极作用，同时会有效地促进高校就业率的提升，促进我国社会经济结构的调整及完善发展。

27 Liao D,Qian YF,Jin B,Wang HL.Shenmai injection for adjuvent treatment of 65 cases of septic shock.Yi Yao Dao Bao 2008;1(27):59-60.

12 Zhang YK,Chen ZX,Gao M.Assessment of clinical effect of shenmai injection for septic shock.Zhong Xi Yi Jie He Shi Yong Lin Chuang Ji Jiu 1998;7(5):43.

13 Long MZ,Ma HR,Long FC,Long MZ.Observation on effect of Shenmai injection in the treatment of cardiogenic shock.Shenzhen Zhong Xi Yi Jie He Za Zhi 2000;6(10):255-257.

14 Xue P.Efficacy observation of Shenmai injection in treatment of 32 shock cases.Zhong Guo Zhong Yi Ji Zheng 2000;2(9):65.

15 Cao YY.Efficacy of Shenmai injection in treatment of 32 shock cases.Jiangsu Zhong Yi 2001;11(22):22.

16 Wu WS,Teng XY.Combination of Traditional Chinese Medicine and Western Medicine in treatment of 34 cases of acute myocardial infarction complicated with cardiogenic shock.Liaoning Zhong Yi Za Zhi 2001;7(28):428.

17 Zhao M,Jiang P,Ma GE.Clinical observation of Shenmai injection in treatment of 33 shock cases.Jiao Tong Yi Xue 2001;5(15):507-508.

18 Yang J.Combination of Traditional Chinese Medicine and Western Medicine in treatment of 51 cases of cardiogenic shock.Huai Hai Yi Yao 2002;4(20):319.

19 Fan J,Liang YS,Jiao QC.Shenmai injection for adjuvent treatment of 30 shock cases.Hebei Zhong Yi 2003;6(25):417-418.

20 Wang ZQ,Feng GC,Chen XR,Wang HY.Efficacy analysis on Shenmai injection in treatment of shock.Yi Yao Lun Tan Za Zhi 2003;13(24):50.

21 Su QH,Yang MJ,Gu ZQ,Huang HX,Guo XP.Clinical effect on Shenmai injection for the treatment of burn shock.Zhong Guo Zhong Xi Yi Jie He Ji Jiu Za Zhi 2004;1(11):57-59.

22 Xu GT.Clinical observation of Shenmai injection for treatment of myocardial infarction complicated with hypovolemic shock.Ji Ceng Yi Xue Lun Tan 2004;8(8):713.

23 Cheng JX,Zhang LH.Efficacy analysis of Shenmai injection in treatment of burn shock.Hubei Zhong Yi Za Zhi 2005;11(27):40.

24 Huang ZL.Efficacy evaluation of Shenmai injection and dopamine in the treatment of 51 cases of cardiogenic shock.Zhong Hua Xian Dai Yi Xue Yu Lin Chuang 2006;10(4):3-4.

25 Liu M.The effect of Shenmai injection in treatment of cardiac shock after acute myocadiac infarction.Zhong Guo Zhong Yi Ji Zheng 2007;7(16):821-822.

F1断裂中节理裂隙较发育，主要有:(1)走向340°、310°的压性和压扭性节理裂隙，呈密集性闭合状，平均线裂隙率20～25条/米；(2)走向190°、倾角75°的压扭性节理裂隙，沿裂面有钙质淋滤作用形成的小孔洞；(3)走向90°、245°的张性裂隙，宽0.4～0.7 cm，局部有渗水现象。

26 Chen YM.Shenmai injection in treatment of 32 shock cases.XianDaiZhongXiYiJieHeZaZhi2008;6(17):901.

由图3可知，1.064 μm在平流雾中的前向散射最强.由表1和表2可知，1.064 μm在平流雾中的散射系数(4.3296 km-1)大于在辐射雾中的散射系数(3.612 3 km-1).说明1.064 μm在平流雾中前向散射大、散射能力强，多次散射对透过率的贡献较大，所以相同传输距离下，1.064 μm在平流雾中的衰减小于在辐射雾中的衰减.

28 Sun SQ.Clinical observation of Shenmai injection in treatment of myocardial infarction complicated with hypovolemic shock.Zhong Guo Xin Yi Xue Lun Tan 2008;2(8):88.

29 Xue JT.Clinical analysis of 100 burn shock cases.Zhong Guo Xian Dai Yao Wu Ying Yong 2009;24(3):89-90.

30 Zhang ZJ,Wu HY,Zhong PF.Effect of Shenmai injection in treatment of 64 shock cases.Zhong Yi Yao Dao Bao 2009;5(15):19-20.

31 Zhao Z,Xie JJ.Clinical application of Shenmai injection in treatment of burn shock.Shandong Yi Yao 2009;24(49):92-93.

32 Guo FD,Yang YF,Yu FY.Clinical study on Shenmai injection combined with western medicine in treatment of traumatic shock.Shi Yong Lin Chuang Yi Yao Za Zhi 2011;21(15):173-174.

33 Zeng MQ.Efficacy analysis of Shenmai injection in treatment of burn shock.Jian Kang Bi Du 2012;2(11):283.

34 Liao QY,Wu XJ,Rong YX,Lin JY,Liao X,He FM.Efficacy of Shenmai injection in treatment of burn shock.Zhong Guo Yi Yao Zhi Nan 2012;18(10):275-276.

35 Pu JW,Liu YL.Clinical research on effect of Shenmai injection combined with Western Medicine in treatment of 23 shock cases.Zhong Guo Yi Yao Zhi Nan 2013;16(11):681-682.

36 Zhang R,Zhang CH,Fu DJ,et al.Therapeutic effect of Shenmai injection in the treatment of septic shock.Hainan Yi Xue 2013;7(24):957-959.

37 Zhao GP,Wu YJ.Shenmai injection on early fluid resuscitation in treatment of hypovolemic shock.Jie Fang Jun Yi Yao Za Zhi 2013;9(25):85-88.

38 Ding Q,Yan C,Liu F.Clinical study on effect of Shenmai injection in the treatment of burn shock.Hang Kong Hang Tian Yi Xue Za Zhi 2014;1(25):81-82.

39 Peng CH.Changes in clinical shock treatment for patients with Shenmai injection flow mechanics and science.Zhong Guo Wei Sheng Chan Ye 2014;36(11):33-34.

40 Song XH,Liu HM,Wang CZ,Jiang CY.Observation on efficacy of Shenmai injection in treatment of cirrhosis.Lin Chuang Xiao Hua Bing Za Zhi 2014;2(26):109-110.

41 Zhang R,Li JG,Li LF.Efficacy of high-dose Shenmai injection for cardiogenic shock.Zhejiang Lin Chuang Yi Xue 2014;10(16):1621-1622.

42 Wang LX,Tang H,Xie YM.Literature review and hospital information system data real world clinical outcome analysis of role of parenterally administered shenmai in treatment of shock.Zhong Guo Zhong Yao Za Zhi 2013;18(38):3104-3109.

43 Zhou Q,Qin WZ,Liu SB,Kwong JS,Zhou J,Chen J.Shengmai(a traditional Chinese herbal medicine)for heart failure.Cochrane Database Syst Rev 2014;4:CD005052.

44 Hu J,Zhang W,Xie YM,Wang LX,Nie XL,Zhang YL.Meta-analysis of Shenmai injection treatment for acute myocardial infarction.Zhong Guo Zhong Yao Za Zhi 2012;18(37):2760-2767.

45 Lu LY,Zheng GQ,Wang Y.An overview of systematic reviews of shenmai injection for healthcare.Evid Based Complement Alternat Med 2014;(2014):840650.

46 Zhang L,Hu J,Xiao L,et al.Adverse drug reactions of Shenmai injection:a systematic review.J Evid Based Med 2010;3(3):177-182.

47 Wang LX,Xie YM.Analysis of clinical safety for Shenmai injection based on literature.Zhong Guo Zhong Yao Za Zhi 2012;18(37):2779-2781.

48 Vickers A,Goyal N,Harland R,Rees R.Do certain countries produce only positive results?A systematic review of controlled trials.Control Clin Trials 1998;2(19):159-166.

49 Tang JL,Zhan SY,Ernst E.Review of randomised controlled trials of Traditional Chinese Medicine.BMJ 1999;7203(319):160-161.