Transcript 臨床問題

OVID MEDLINE
實證醫學乃是從龐大的醫學資料庫中搜尋相關文獻，
並以流行病學及統計學方法過濾出值得信賴的文獻，
再經過嚴格評讀及綜合分析後，將所獲取之最佳研
究證據 (evidence) 、臨床經驗 (experience) 及患者期望
(expectation) 相互整合，配合診療情境後制定出一套
最佳的臨床醫療決策，並可用來協助醫護人員進行
終身學習。
Not only a skill but also an attitude change
for everyone in hospitals
臨床決策模型
J Am Med Inform Assoc. 1997 Jul-Aug;4(4):266-78. Elson RB, Faughnan JG, Connelly DP
實證醫學三大要素
Evidence
EBM
Experience
Expectation
臨床問題從哪裡來？
 臨床發現 ( clinical findings )
 病因 ( etiology )
 疾病的臨床表徵( clinical menifestations of






diseases )
鑑別診斷與診斷檢查 ( DDx & diagnostic test )
治療 ( therapy)
預後 ( prognosis )
預防措施 ( prevention )
（生病）的經驗與意義 ( experience & meaning )
自我學習發展的過程 ( self-improvement )
臨床問題的種類
 Therapy/Prevention：治療/預防的問題
研究治療或預防方法的有效性
例如：服用“阿斯匹林”是否可以預防中風？
 Diagnosis：診斷問題
研究檢查方法或臨床表徵對疾病診斷的有效性
例如：McBurney’s sign 診斷急性盲腸炎的敏感度及特異度為何？
 Harm/Etiology：危害/病因問題
研究暴露的危害或疾病的原因
例如：停經婦女使用荷爾蒙治療是否會增加乳癌的機會？
 Prognosis：預後
建立疾病預後的預測模式
例如：利用Ranson’s criteria 預測急性胰臟炎死亡率為何？
例如: In healthy women who have recently had a miscarriage(流
產), what is the usual grieving(悲傷) process and are any factors
associated with longer than normal grieving?
Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001)
Leve
l
Therapy/Prevention,
Aetiology/Harm
Prognosis
Diagnosis
1a
SR (with homogeneity*) of
RCTs
1b
Individual RCT (with narrow
Confidence Interval‡)
SR (with homogeneity*) of
inception cohort studies;
CDR† validated in different
populations
Individual inception cohort
study with > 80% followup; CDR† validated in a
single population
SR (with homogeneity*) of
Level 1 diagnostic studies;
CDR† with 1b studies from
different clinical centres
Validating** cohort study
with good††† reference
standards; or CDR† tested
within one clinical centre
1c
All or none§
All or none case-series
All or none case-series
2a
SR (with homogeneity*) of
cohort studies
2b
Individual cohort study
(including low quality RCT;
e.g., <80% follow-up)
SR (with homogeneity*) of
either retrospective cohort
studies or untreated control
groups in RCTs
Retrospective cohort study
or follow-up of untreated
control patients in an RCT;
Derivation of CDR† or
validated on splitsample§§§ only
Absolute SpPins and
SnNouts††
SR (with homogeneity*) of
Level >2 diagnostic studies
Exploratory** cohort study
with good†††reference
standards; CDR† after
derivation, or validated only
on split-sample§§§ or
databases
Retrospective cohort study,
or poor follow-up
2c
"Outcomes" Research;
Ecological studies
SR (with homogeneity*) of
case-control studies
Individual Case-Control
Study
"Outcomes" Research
Case-series (and poor
quality cohort and casecontrol studies§§)
Expert opinion without
explicit critical appraisal, or
based on physiology, bench
research or "first principles"
Case-series (and poor
quality prognostic cohort
studies***)
Expert opinion without
explicit critical appraisal, or
based on physiology, bench
research or "first principles"
3a
3b
4
5
Differential
diagnosis/symptom
prevalence study
SR (with homogeneity*) of
prospective cohort studies
Economic and decision
analyses
Prospective cohort study
with good follow-up****
Analysis based on clinically
sensible costs or
alternatives; systematic
review(s) of the evidence;
and including multi-way
sensitivity analyses
Absolute better-value or
worse-value analyses ††††
SR (with homogeneity*) of
Level >2 economic studies
SR (with homogeneity*) of
2b and better studies
Ecological studies
SR (with homogeneity*) of
Level 1 economic studies
Analysis based on clinically
sensible costs or
alternatives; limited
review(s) of the evidence,
or single studies; and
including multi-way
sensitivity analyses
Audit or outcomes research
SR (with homogeneity*) of
3b and better studies
Non-consecutive study; or
without consistently applied
reference standards
SR (with homogeneity*) of
3b and better studies
Non-consecutive
cohort study, or very
limited population
Case-control study, poor or
non-independent reference
standard
Expert opinion without
explicit critical appraisal, or
based on physiology, bench
research or "first principles"
Case-series or superseded
reference standards
SR (with homogeneity*) of
3b and better studies
Analysis based on limited
alternatives or costs, poor
quality estimates of data,
but including sensitivity
analyses incorporating
clinically sensible
variations.
Analysis with no sensitivity
analysis
Expert opinion without
explicit critical appraisal, or
based on physiology, bench
research or "first principles"
Expert opinion without
explicit critical appraisal, or
based on economic theory
or "first principles"
New
http://www.cebm.net/index.aspx?o=5653 10 June 2010
研究設計分類
( A taxonomy of clinical research)
by David A Grimes, Kenneth F Schulz,2002
Did investigator
Assign exposures?
Yes
No
Experimental study
Observational study
Random allocation?
Comparison group?
Yes
Randomized
Controlled trial
Yes
No
NonRandomized
Controlled trial
Analytical
study
No
Descriptive
study
Direction？
Exposure  Outcome
Exposure and Outcome
at same time
Exposure  Outcome
Cohort
study
Case-control
study
Crosssectional
study
The “6S” levels of organization of
evidence from health care research
Computerized decision support
Computer
Evidence-based clinical practice guidelines
Evidence based textbook
Summaries
ACP Journal Club、DARE
Systematic reviews
ACP Journal Club
Original journal articles
Synopses of Syntheses
Syntheses
Synopses of studies
Studies
by R Brain Haynes, 2009
二次研究證據 (已經整理的文獻)
1. System系統

2. Summaries – for Background questions
 (1) Evidence-based CPG (free)
 (2) Best Practice-Clinical Evidence
 (3) UpToDate
 (4) ACP Pier & ACP Medicine
 (5) FirstConsult
 (6) DynaMed
 (7) Medscape-eMedicine (free)

3. Synopses精要（ Article reviews ） - for Background questions
 (1) ACP Journal Club
 (2) Evidence-based Medicine
 (3) Evidence-based Nursing

4. Syntheses統整（ Systematic reviews ） - for Foreground question
 (1) The Cochrane Library - CDSR & Other Reviews (中文版摘要 free)
 (2) PubMed-Clinical Queries之 systematic review (free)
 (3) Medline之systematic review
原始研究證據 (未經整理的文獻)

自
二
次
研
究
證
據
找
起
)
5. Studies（ Original journals articles ）- for Foreground question
 (1) The Cochrane Library- Clinical trials
 (2) PubMed -Clinical Queries之Clinical study search (free)
 (3) Medline (善用 more limit之功能)
搜
尋
流
程
(

OVID MEDLINE
收錄年代：1946~Current
收錄主題範圍
基礎醫學
臨床醫學
生物科學
解剖學
醫務管理學
化學與藥物
心理學
社會醫學
生物農業與營養
醫材設備
醫事技術
醫事資訊
收錄內容：文獻之書目資料、摘要
MeSH 醫學標題
Title
FRAX or fiction: determining optimal screening strategies for treatment
of osteoporosis in residents in long-term care facilities.
主標題：Osteoporosis
Diphosphonates
Cross-Sectional Studies
副標題：
Diagnosis
Osteoporosis
Drug therapy
Epidemiology
文獻的重點為討論osteoporosis的流行病學
研究，但文中有討論到治療及藥物治療
而且是以Diphosphonates為主要治療用藥
什麼是MeSH？
運動、遊戲、娛樂圈、音樂.....什麼都有
– NLM在分析生物醫學方面之期刊文獻、圖書、視
聽資料、電子資源等資源的主題時，為了將同一
概念用固定的詞彙表達，於是建立一套醫學標題
詞（MeSH），以達到控制詞彙的目的。
– 索引專家們更在眾多標題詞中建立主題關係連結，
可利用樹狀結構圖呈現出詞彙間語義或從屬上的
關係。
以固定的詞彙表達
1. 彙整同義詞至同一標題詞(MeSH)
標題詞(MeSH)
彙整的同義詞
2. 彙整相同主題的文章至同一標題詞(MeSH)
標題詞(MeSH)
樹狀結構
二次研究證據 (已經整理的文獻)

1. System系統
原始研究證據 (未經整理的文獻)

自
二
次
研
究
證
據
找
起
)
6. Studies（ Original journals articles ）
 (1) The Cochrane Library- Clinical trials
 (2) PubMed -Clinical Queries之Clinical study search (free)
 (3) Medline (善用 more limit之功能)
搜
尋
流
程
(
2. Summaries
 (1) Best Practice-Clinical Evidence
 (2) UpToDate
 (3) ACP Pier & ACP Medicine
 (4) DynaMed
 (5) Medscape-eMedicine (free)
 3. Synopses of Syntheses
 (1) ACP Journal Club
 (2) Evidence-based Medicine
 (3) Evidence-based Nursing
 (4) Database of Abstracts of Reviewsof Effects (DARE)
 4. Syntheses統整（ Systematic reviews ）
 (1) The Cochrane Library - CDSR & Other Reviews (中文版摘要 free)
 (2) ACPJC PLUS
 (3) Medline之systematic review
5.Synopses of Syntheses

臨床問題
Which therapy have more benefit for Atopic Dermatitis
either Tacrolimus or Corticosteroids.
原始關鍵字Primary
Term 或MeSH Term
同義字1
同義字2
P
(
Atopic Dermatitis
with children
or
or
)
and
I
(
Tacrolimus
or
or
)
and
C
(
Corticosteroids
or
or
)
and
O
(
quality of life
or
or
)
OVID MEDLINE 文獻檢索主要步驟
檢索
條件限制
自然語言、關鍵字
MeSH
Clinical Queries
Publication Type
輸出
全文、內容
書目資料管理
檢
索
BASIC Searsh
Advanced Search(MeSH)
選擇主標題
選擇副標題
(找尋以prevention為主要研究方向的文獻)
條件限制
Clinical Queries(找回reviews的文獻)
Sample年齡
期刊收錄主題
出版語系
以語彙控制為工具針對臨床
行為做分類，senstivity為最嚴
格、best balance次之，
specificity為較鬆散的條件
文獻研究方法
Publication types & subject subsets
(systematic revews、mata-analysis、RCTs)
Meta analysis 4 篇
Systematic Review 14 篇
RCTs 35 篇
輸
出
全文輸出
輸出勾選文獻的
書目資料
Thank You!