實(shí)證醫(yī)學(xué)課件-臺(tái)灣大學(xué)

循證醫(yī)學(xué)Evidence-BasedMedicine目錄■循證醫(yī)學(xué)介紹

(slide1-42)及教學(xué)應(yīng)用■提出臨床問(wèn)題

(PICO)提升文獻(xiàn)搜索技能

(cite

references)■

嚴(yán)格文獻(xiàn)評(píng)讀■

實(shí)例練習(xí)病歷紀(jì)錄引用參考文獻(xiàn)(PubMedor

UpToDate…)MedicalEducationintheNewCenturyBioinformaticsEthicsHumanitiesPatient-centered

careProblem-based

learningEvidence-based

medicine※定義：Useofcurrentbestevidenceinmakingdecisionsaboutthecareofindividualpatients.※EBM(EBN,EBP)istheintegrationofbestresearchevidencewithclinicalexpertiseandpatients’uniquebiology,valuesandcircumstances(patient’sexpectation).(Evidence-basedPractice)(Sackett&Straus)Evidence-BasedMedicineDrPt EvDecisionMakinginHealthCareSearchingbibliographicdatabasesClinicalpracticeguideline

(CPG)Evidence-basedjournal

abstracts“Dono

harm”Whatyou

learnedduringyourprofessionaltrainingBrowse

journalsTextbooksAsk

colleaguesChartrecord–citereference病歷紀(jì)錄引用文獻(xiàn)1. Formulateananswerablequestion.~Ask(PICO)提問(wèn):由個(gè)案的臨床資料提出可回答的臨床問(wèn)題2.Trackdownthebestevidence.~Acquire(Citepaper)尋找最佳的實(shí)證文獻(xiàn)﹝各種文獻(xiàn)資料庫(kù)，包括發(fā)表及未發(fā)表的資料﹞Criticallyappraisetheevidenceforvalidity,impact,andapplicability.~Appraisal(VIP)評(píng)估最佳實(shí)證醫(yī)學(xué)文獻(xiàn)的可信度、臨床重要性、以及可應(yīng)用性Integratewithourclinicalexpertiseandpatient

values.整合並應(yīng)用於實(shí)際患者的治療決策~﹝臨床應(yīng)用﹞告知

~Apply(3E)Evaluateoureffectivenessandefficacy.效果評(píng)估~

Audit溝通用簡(jiǎn)單且病人可以聽(tīng)懂的語(yǔ)言，告知各種處置之可能利益與風(fēng)險(xiǎn)實(shí)證醫(yī)學(xué)的五大進(jìn)行步驟FiveStepstoPracticeEBM(5As)臨床問(wèn)題類(lèi)型診斷

(Diagnosis)Sensitivity,

specificity 敏感度、特異度Predictivevalue(PPV,NPV)

陽(yáng)性預(yù)測(cè)值、陰性預(yù)測(cè)值ROCcurve,Likelihoodratio(LR+,LR-)

概似比治療

(Therapy)Clinicaltrial(RandomizedControlledTrial,RCT,

RR)預(yù)後

(Prognosis)Predictionmodel(Survivalanalysis,HR

風(fēng)險(xiǎn)比)危險(xiǎn)因子探討(Risk

factor)Cohortstudy(RelativeRisk,RR

相對(duì)風(fēng)險(xiǎn)比)Case-controlstudy(Odds

Ratio,

OR 勝算比)Step

1. Convertingtheneedforinformation

(about

prevention,diagnosis,prognosis,therapy,causation,etc.)intoananswerablequestion.(Ask)-

PICOStep

2. Searchingthebestevidencewithwhichto

answer

thatquestion.

(Acquire)Step

3. Criticallyappraisingtheevidencefor

itsvalidity(closenesstothetruth),impact(sizeoftheeffect),andapplicability(usefulnessinourclinicalpractice).((AApppprraaiissaall))-

VIPStep

4. Integratingtheevidencewithourclinical

expertise

andpatients’uniquebiology,valuesandcircumstances.(Apply)-3

EStep

5. Evaluatingoureffectivenessandefficiency

in

executingsteps1-4andseekingwaystoimprovethemfornexttime.

(Audit)實(shí)證醫(yī)學(xué)的五大進(jìn)行步驟FiveStepstoPracticeEBM(5Ass)I 隨機(jī)控制對(duì)照研究Meta-analysisII世代研究III病例對(duì)照研究IV病例報(bào)告及系列V 個(gè)人意見(jiàn)、動(dòng)物及試管研究Animal,testtuberesearch統(tǒng)計(jì)方法Meta-analysis統(tǒng)合分析圖示結(jié)果Forestplot研究設(shè)計(jì)與證據(jù)強(qiáng)度(Bias,Robust)Hierarchyofevidence:arrangesstudydesignsbytheirsusceptibilitytobias.(Robust)RandomizedControlledTrials(RCT)~ I研究設(shè)計(jì)與證據(jù)強(qiáng)度TheEvidencePyramidLevelofEvidenceI~VDoubleBlindedRCTModifyfrom:OxfordCenterforEBMGradeofRecommendationLevelofEvidenceTherapy[A]From:OxfordCenterforEBM1aSystematicreview(withhomogeneity)ofRCTs1bSingleRCT(randomizedcontrolledtrial)1c‘All-or-none’[B]研究設(shè)計(jì)與證據(jù)的強(qiáng)度Evidence-BasedMedicine:HowtoPracticeandTeachEBM.2nded.DavidL.Sackett,SharonE.Straus,W.ScottRichardson,WilliamRosenberg,R.BrianHaynes.ChurchillLevingstone.2000,p173-177Guideline證據(jù)等級(jí)（LevelsofEvidence）:臨床指引(Guideline)建議的形成是根據(jù)文獻(xiàn)的證據(jù)等級(jí)而來(lái)，建議強(qiáng)度與證據(jù)等級(jí)有關(guān)，但建議強(qiáng)度並非表示建議的重要2aSystematicreviewofcohortstudies2bCohortstudyorpoorRCT2c‘Outcomes’research3aSystematicreviewofcase-controlstudies3bCase-controlstudy性。[C]4Caseseries[D]5Expertopinion,physiology,benchresearchUSPreventiveServicesTaskForceRatingSystemofQualityofScientificEvidenceI:Evidenceobtainedfromatleast1properly

designed,randomizedcontrolled

trialII-1:Evidenceobtainedfrom

well-designedcontrolledtrialswithout

randomizationII-2:Evidenceobtainedfromwell-designedcohortorcase-controlanalyticstudies,preferentiallyfrommorethan1centeror

groupII-3:Evidenceobtainedfrommultipletimeserieswithorwithouttheintervention,ordramaticresultsinuncontrolledexperiments(suchastheresultsoftheintroductionofpenicillintreatmentinthe

1940s)III:Opinionsofrespectedauthorities,basedonclinicalexperience,descriptivestudies,orreportsofexpert

committees實(shí)證醫(yī)學(xué)沿革■ 1972年英國(guó)臨床流行病學(xué)者ArchieCochrane提出實(shí)證醫(yī)學(xué)的概念。~ 所有醫(yī)療行為都應(yīng)有嚴(yán)謹(jǐn)研究且證實(shí)為有效的根據(jù)，才能將醫(yī)療資源做最有效的運(yùn)用，並強(qiáng)調(diào)Randomized controlled trials 的重要性。﹝*無(wú)效果之檢驗(yàn)或治療不要做﹞■ 1992英國(guó)國(guó)家衛(wèi)生部成立實(shí)證醫(yī)學(xué)中心，並以ArchieCochrane之名命名，進(jìn)而促使1993年CochraneCollaboration的設(shè)立。(IainChalmers,DavidSackett)Lancet曾把CochraneCollaboration比作臨床醫(yī)學(xué)的人類(lèi)基因組計(jì)劃分配：Experimentalstudy實(shí)驗(yàn)性研究vs.觀察性研究Observational

study時(shí)間：Longitudinal(prospectiveorretrospective)vs.Cross-sectional

studyStudyDesignStudyDesignStudyDesignStudyDesign研究開(kāi)始問(wèn)題(用途)研究種類(lèi)時(shí)間性過(guò)去現(xiàn)在未來(lái)Cross-sectional(prevalence)橫斷性觀察7收集資料7Case&non-Case盛行率、診斷Cohort(longitudinal)縱向性(前瞻)定義世代並評(píng)估危險(xiǎn)因子觀察結(jié)果Y*N發(fā)生率、病程預(yù)後、病因ClinicalTrial(experimental)縱向性(前瞻)作治療﹝治療組與對(duì)照組﹞觀察結(jié)果Y*N藥物療效評(píng)估Casecontrol(retrospective)縱向性(回溯)評(píng)估危險(xiǎn)因子Exposure:Y*N界定病例組與非病例組病因﹝尤其罕病﹞Repeatedcross-sectional橫斷性觀察收集資料7重複收集77隨時(shí)間改變CalculationofRR,ORRiskfactor(Treatment)Event(Disease)PositiveDiseasedNegativeNon-diseasedExposed(Experimentalgr.)A= 1B= 29Notexposed(Controlgroup)C= 9D= 21EER,experimentaleventrate=a/a+b=0.033 (Cohortstudy,RCT)CER,controleventrate=c/c+d=0.301.RelativeRisk=Riskratio=EER/CER=(a/a+b)/(c/c+d)=0.11風(fēng)險(xiǎn)指標(biāo):RelativeRisk(ratio)=EER/CERvs.AbsoluteRisk(difference)=│EER–CER│vs.NNT=1/ARR(Case-controlstudy)*ExperimentaleventOdds=a/b=0.034*ControleventOdds=c/d=0.432.*RelativeOdds=*OddsRatio=(a/b)/(c/d)=ad/bc=0.08Inrareevent(盛行率<10%),OR≒RROdds:aratioofeventstonon-events=p/(1-p)vs.Probability=event/(event+non-event)TreatmentofClassIII-IVLupusNephritisMeta-Analysis(poolingstudies)Treatmentofdiffuseproliferativelupusnephritis:Ameta-analysisofrandomizedcontrolledtrialsAmJKidneyDis.2004Feb;43(2):197-208.CochraneRenalGroupCochraneDatabaseofSystematic Reviews.1,2004.2004AJKDAmJKidneyDis.2004;43:197-208.CochraneRenalGroupCochraneDatabaseofSystematicReviews2004.0Summaryeffect::Diamond-shapedsymbolsrepresentthesummaryestimatorofoveralleffectpoolingtheweightedeffectofindividualRCTs.4NullHypothesis(虛無(wú)假設(shè)RR,OR,orHR=1,meandifference,effectsize=0):averticallineat1.0representingequivalenceinriskforanoutcomewithexperimentalandcontroltreatment.ValuesofRRlessthan1indicateareductioninriskfortheoutcomewiththeexperimentaltreatment.Conversely,valuesofRRmorethan1indicateanincreaseinrisk.OPointestimateand95%CI(點(diǎn)估計(jì)與區(qū)間估計(jì)):TheRRforeachoutcomeandits95%CIareindicatedbyasolidsquareandaline.The95%CIsareameasureofvariabilityintheprecisionoftheRRestimateanditsstatisticalsignificance.Thesizeofthesolidsquarerepresentsthecontribution(weight)ofthetrialtotheanalysis.oHeterogeneity(‘non-combinabilityifp<0.05’)oftreatmenteffectsbetweenstudieswasinvestigatedbyvisualexaminationofgraphicmeta-analysisplotsandfromtheCochranQ(heterogeneitychi-square)andI2statistic.04Ooa/a+bc/c+dAmJKidneyDis.2004;43:197-208.CochraneRenalGroupCochraneDatabaseofSystematicReviews2004.Forestplot (Meta-analysis)RR=a/a+b÷c/c+dWeighting(wi)=1/Variance(變異數(shù)的倒數(shù))Overallestimate:log(RR)=

Wi*log(RRi)/

WiO■

點(diǎn)估計(jì)0.6(區(qū)間估計(jì)0.36~0.99)TreatmentofProliferativelupusnephritis嚴(yán)格評(píng)讀~研究方法的品質(zhì)：如隨機(jī)產(chǎn)生方式、隱密性，盲性，ITT及失聯(lián)比率。(評(píng)讀的Checklist:Jadadscore,Grademethod,VIP,RAMbo,CAT,CASP…)進(jìn)階學(xué)習(xí)與教學(xué)目前國(guó)外推動(dòng)實(shí)證醫(yī)學(xué)著名的單位英國(guó)OxfordUniversity的CentreforEvidence-Based

Medicinehttp://cemb.jr2.ox.ac.uk(CATmaker計(jì)算器:95%CI,CATform)加拿大McMasterUniversity的HIRU(HealthInformationResearchUnit)是Cochrane

Collaboration重鎮(zhèn)http://hiru.mcmaster.ca/美國(guó)AmericanCollegeofPhysician（ACP），出版ACPJournalClub

Online

NGC-NationalGuidelineClearinghouseAGREE-appraisalofguidelineresearch&

evaluation/GuidelinesInternationalNetwork

(GIN)http://www.g-I-/SIGN-ScottishIntercollegiateGuidelines

Networkhttp://www.sign.ac.uk/NICE-NationalInstituteforHealthandClinical

Excellence.uk/ResourceCentersforGuidelinesNationalLibraryforHealth

(NLH)>12,000http://www.library.nhs.uk/Default.aspxNZGG-NewZealandGuidelines

Group.nz/NationalHealthandMedicalResearch

Council.au/CenterforEvidence-basedMedicine,

Oxford/CMAInfobase(CanadianMedical

Association)http://mdm.ca/cpgsnew/cpgs/index.asp■臺(tái)灣實(shí)證臨床診療指引平臺(tái)(建置中).tw/ResourceCentersforGuidelines學(xué)習(xí)目標(biāo)“LearningbyDoing”Fivestepsinpracticing

EBMFormulateclinicalquestion~PICO

principleSearch

databaseCochranedatabase,CCTR,DARE,ACPjournal

clubUpToDatePubMed-Clinicalqueries(highqualityfilter)

etc.Micromedex,

CINHAL…Judgelevelofevidence(研究設(shè)計(jì)),criticalappraisal(VIPprinciple,RAMbo,Criticalappraisalsheet,

CASP…)CalculateNNT,

NNHnumberneededtotreat(NNT=

1/ARR)numberneededtoharm(NNH=

1/ARI)Readforestplot

(meta-analysis)Practice主動(dòng)積極自我學(xué)習(xí)Attitudeandbehavior

changeapplytopatientcareandchartrecord(cite

reference!).我家裡老大有氣喘，如果我吃益生菌，可以預(yù)防第2胎新生兒氣喘的發(fā)生嗎？實(shí)例練習(xí)Scenario臨床情境■ 28歲懷孕三個(gè)月的母親，帶著2歲有氣喘的兒童，到婦兒科門(mén)診，問(wèn)優(yōu)酪乳可不可以預(yù)防或減少未來(lái)新生兒過(guò)敏病(氣喘)的發(fā)生？■Q&A:益生菌(probiotics)、優(yōu)酪乳可不可以預(yù)防或減少過(guò)敏氣喘病發(fā)生或嚴(yán)重程度？■電視、報(bào)紙、PubMed上、許博士說(shuō)：喝優(yōu)酪乳增加腸道益生菌減少氣喘等效果?！觥阂嫔?Probiotics)就是對(duì)身體友好處的「好菌」，是一種可改善宿主腸內(nèi)菌相平衡，有益宿主健康之活微生物體。例如一般人熟悉的A、B菌，被認(rèn)為具有保健效益，主要為乳酸菌和部分酵母菌。■『益菌生』（Prebiotics，又稱(chēng)為益生源）又是什麼？它是指可以刺激腸道裏的好菌生長(zhǎng)的「食物」，這類(lèi)的物質(zhì)如我們常聽(tīng)到的膳食纖維和果寡糖就是?！阂婢晃镔|(zhì)能夠被有益菌利用而產(chǎn)生有機(jī)酸，刺激腸蠕動(dòng)，並且能促進(jìn)有益菌生長(zhǎng)，抑制壞菌數(shù)量，使腸道更健康?！隹茖W(xué)家發(fā)現(xiàn)，人體免疫樞紐地位的細(xì)胞T淋巴球，由所分泌的細(xì)胞素不同而分成二型（簡(jiǎn)稱(chēng)Th1,Th2），兩者間具有動(dòng)態(tài)的平衡關(guān)係，影響免疫系統(tǒng)對(duì)抗原的反應(yīng)，如Th2反應(yīng)太強(qiáng)，就會(huì)出現(xiàn)過(guò)敏癥狀。初生嬰兒的免疫機(jī)制偏向易造成過(guò)敏的Th2，益生菌有助新生兒建立平衡的Th1／Th2免疫機(jī)制。1.Formulateananswerablequestion.(Ask:PPIICCOO*)由個(gè)案的臨床資料形成可回答的臨床問(wèn)題*(PICO)2. Trackdownthebestevidence.(Acquire:citeref.)尋找最佳的實(shí)證﹝各種文獻(xiàn)及資料庫(kù)，包括發(fā)表及未發(fā)表的資料﹞3.CCrriittiiccaallllyyaapppprraaiisseetheeevviiddeenncceeforvvaalliiddiittyy,,impact,andapplicability.(Appraisal:VIP)評(píng)估各種醫(yī)學(xué)報(bào)告的可信度、臨床重要性，以及可應(yīng)用性Integratewithourclinicalexpertiseandpatient

values.整合並應(yīng)用於實(shí)際患者的治療決策﹝臨床應(yīng)用﹞(Apply:3

E)Evaluateoureffectivenessandefficacy.(Audit)效果評(píng)估告知以病人可以聽(tīng)懂的語(yǔ)言，告知各種處置之可能利益與風(fēng)險(xiǎn)

(%)實(shí)證醫(yī)學(xué)的五大進(jìn)行步驟FiveStepstoPracticeEBM(5As)1.AskingAnswerableClinicalQuestions(PICO)Well-builtClinicalQuestion“Background”

questionAskgeneralknowledgeabouta

disorderHavetwoessential

components:Aquestionroot(who,what,why,when,how,why,where)witha

verbAdisorder,oranaspectofa

disorder“Foreground”

questionAskforspecificknowledgeaboutmanagingpatientswitha

disorderHavefour(orthree)essentialcomponents

(PICO):1.Patient/Problem:Whoisthepatientorwhatistheproblembeingaddressed?

(病人族群與特徵)2.Intervention:Whatisthe

intervention

(treatment)? (A

處置或檢驗(yàn))3.Comparisonintervention:Whatare

the

alternatives? (B

處置或檢驗(yàn))4.Outcomes:Whataretheoutcomes?

(重要的臨床結(jié)果、指標(biāo))Patient~Whoisthepatientorwhatistheproblembeingaddressed?病人問(wèn)題Intervention~Whatistheintervention?(A)介入處置或檢驗(yàn)Comparison~Whatarethealternatives?(B)對(duì)照的處置或檢驗(yàn)(其它的選擇)Outcome~Whataretheoutcomes?重要的臨床結(jié)果、指標(biāo)ThereAreFourElementsofaWell-formulatedQuestion~ usePPIICCOOformat~1.AskingAnswerable ClinicalQuestion(PICO)Patient/Problem病人問(wèn)題孕婦(有氣喘家族史)Intervention介入處置(檢查)吃益生菌(probiotics)Comparison對(duì)照的處置不吃益生菌Outcomes臨床結(jié)果減少新生嬰兒氣喘的發(fā)生率Step1.提出問(wèn)題的要點(diǎn): *Asspecificaspossible!Scenario臨床情境:Ask~PICOPatientInterventionComparisonOutcomePassengerStockingNostockingDVTPopulationInfluenzavac.NovaccineURI%SLEnephritisEndoxan/steroidSteroidMortality/ESRDOsteoporosisHormoneNohormoneCancerBell’spalsyAcutecoronaryAnti-virus/SteroidTroponinIObservationCPK-MBComplicationDiagnosisKawasakiHighdoseaspirinLowdoseaspirinaneurysm2.SearchingTheBestEvidence尋找最佳實(shí)證資料直接使用次級(jí)醫(yī)學(xué)資料庫(kù) (secondary

journals

ordatabases)~ACPjournalclub,Cochranedatabase,CINAHL(CumulativeIndextoNursingandAlliedHealthLiterature),

Micromedex…同時(shí)尋找原始研究論文資料庫(kù) (primary

journals

ordatabases)

~ 如 Medline,NEJM,

Lancet…■ 原則：搜尋與病人問(wèn)題相同或類(lèi)似且證據(jù)等級(jí)(level

ofevidence–由上往下topdown)

較高之文獻(xiàn)，再謹(jǐn)慎嚴(yán)格評(píng)讀與評(píng)估此文章的證據(jù)在此問(wèn)題的適用性。1.Cochranelibrary,CCTR*,ACPjournalclub,DARE■2.UUppTTooDDaattee,MDconsult3.PPuubbMMeedd,

Medline,

CINAHLMeta-analysisSystematic

reviewCochrane(keyword

關(guān)鍵字)Clinicalqueries*

(高品質(zhì))Clinical

evidenceBest

evidenceGuidelines

Clearinghouse(Evidenceisneverenough)

…ClinicalqueriesFree:/cochrane/cochrane_search_fs.htmlSearchtheBestEvidence5S EBM Resources(非關(guān)證據(jù)強(qiáng)弱!)Modelfrom:Haynes,R.B.(2006).Ofstudies,syntheses,synopses,summaries,andsystems:the"5S"evolutionofinformationservicesforevidence-basedhealthcaredecisions.ACPJournalClub,145(3),A8.整合證據(jù)提供特定臨床問(wèn)題之概述與建議ACPPIERBMJClinicalEvidenceDynaMedMDconsultUpToDate對(duì)單篇研究或回顧性文獻(xiàn)作摘要評(píng)述ACPJournalClub,Evidence-BasedMedicine(PubMed,OvidMedline)特定臨床問(wèn)題的系統(tǒng)性評(píng)論文獻(xiàn)CochraneDatabaseofSystematicReviewsDatabaseofAbstractsofReviewsofEffects(PubMed,OvidMedline):SystematicReviews連結(jié)個(gè)別病歷的臨床知識(shí)與支援決策系統(tǒng)原始文獻(xiàn)originalstudies(PubMed,OvidMedline,CINAHL,EMBASECochraneCENTRAL,GoogleScholarCEPS中文電子期刊,中文期刊篇目索引)3.Synopses4.Syntheses5.Studies1.Systems2.SummariesPre-filteredSecondaryPrimaryLevelofEvidenceI~VI 隨機(jī)控制對(duì)照研究DoubleBlindedRCTMeta-analysisIV病例報(bào)告及系列統(tǒng)計(jì)方法Meta-analysis圖示結(jié)果ForestplotV 個(gè)人意見(jiàn)、動(dòng)物試管研究研究設(shè)計(jì)與證據(jù)強(qiáng)度(Bias,Robust)Hierarchyofevidence:arrangesstudydesignsbytheirsusceptibilitytobias.(Robust)RandomizedControlledTrials(RCT)~ I研究設(shè)計(jì)與證據(jù)強(qiáng)度II世代研究III病例對(duì)照研究CurrentBestEvidenceTheBestEvidenceDependsontheTypeofQuestionWhatarethe

phenomena/problems?ObservationWhatisfrequencyoftheproblem?

(Frequency)Random(orconsecutive)

sampleDoesthispersonhavetheproblem?

(Diagnosis)Random(orconsecutive)samplewithgold

standardWhowillgettheproblem?

(Prognosis)Follow-upofinception

cohortHowcanwealleviatetheproblem?

(Therapy)Randomizedcontrolledtrial

(RCT)Thankyou!■以下slide43-79為參考附件Q&

ABooleanAND,OR,

NOTTruncation:

$ *Combinetextwords/keywords/MeSHwith

ORTextwords/keywords的部分，最好能善用truncation

的功能要找有關(guān)Salmonella的資料，但論文中有時(shí)以Salmonellosis表示，這時(shí)你可以用Salmonell$orSalmonell*代表所有Salmonell開(kāi)頭的字串！MeSH(MedicalSubjectHeading)in

PubMedFreetextsearching,limit

function…■ 將P/I/C/O分別轉(zhuǎn)換成不同的字串／關(guān)鍵字／MeSH

再搜尋KawasakiAspirinmucocutaneouslymphnodesyndromesalicylicacid salicyl*CoronaryaneurysmSearchStrategy搜尋策略Scenario臨床情境Patientand/or

problem:A3-y-oKawasakidiseasechildrenwithhighfeverfor5

days.Intervention:IVIGandHighdoseaspirin(30-100mg/kg/d)(treatmentA)–anti-inflammation

doseComparison

intervention:IVIGandLowdoseaspirin(3-5mg/kg/d)(treatmentB)–anti-platelet

doseOutcomes:Coronaryarteryaneurysm(%)重要結(jié)果

outcomeKeywords: xxxandxxxand(Cochraneormeta-analysisorSystematicreview) Dr.YuMeSH高品質(zhì)過(guò)濾資料使用ClinicalQueries來(lái)加速得到高等級(jí)實(shí)證醫(yī)學(xué)證據(jù)CClliinniiccaallQQuueerriieess使用ClinicalQueries來(lái)加速得到高等級(jí)證據(jù)Q&A:哪一篇是Bestevidence?嚴(yán)格評(píng)讀文章2009.061.2.3.4.5.6.7.OsbornDA.Probioticsininfantsforpreventionofallergicdiseaseandfoodhypersensitivity.CochraneDatabaseSystematicReview2007;CD006475KoppMV.Randomized,double-blind,placebo-controlledtrialofprobioticsforprimaryprevention:noclinicaleffectsofLactobacillusGGsupplementation.Pediatrics2008;121:e850-6Kalliom?kiM.Probioticsinprimarypreventionofatopicdisease:arandomisedplacebo-controlledtrial.Lancet2001;357:1076-9BlumerN.PerinatalmaternalapplicationofLactobacillusrhamnosusGGsuppressesallergicairwayinflammationinmouseoffspring.ClinExpAllergy2007;37:348-57乳酸菌達(dá)人 氣喘過(guò)敏兒的實(shí)驗(yàn)報(bào)告~臺(tái)灣氣喘衛(wèi)教學(xué)會(huì)理事長(zhǎng)徐世達(dá)醫(yī)師 過(guò)敏氣喘照護(hù)的新觀念：益生菌的功能VliagoftisH,etal.Probioticsforthetreatmentofallergicrhinitisandasthma:systematicreviewofrandomizedcontrolledtrials.AnnAllergyAsthmaImmunol2008;101:570-9KuitunenM,etal.ProbioticspreventIgE-associatedallergyuntilage5yearsincesarean-deliveredchildrenbutnotinthetotalcohort.JAllergyClinImmunol2009;123:335-413.如何評(píng)讀論文V-I-Pprinciple(RAMbo,CAT,CASP,Gateframe...)Yes ?

No □?

UnclearHowdoIapplytheresultstothecareofmypatients? Both1&2

(V-I-P)?AretheresultValid?(可信度：文章結(jié)果可信嗎?

Truth?)?WhatistheImpact?(重要性：效果大小Sizeoftheeffect

NNT)Practicalin

Practice?3.CriticallyAppraisingtheEvidence治療文獻(xiàn)(RCT)論文評(píng)讀重點(diǎn)病人的分組是隨機(jī)分派的嗎？(randomallocation)分派的方法是否保密？(concealmentofallocation)Yes?

No1.2.3.4.5.6.7.■追蹤是否完整？(follow-upduration)(>80%)(失聯(lián)者少於20%)?Yes治療方法對(duì)病患、醫(yī)護(hù)人員、研究者是否blinded？? Yes分析是否利用Intention-to-Treatanalysis(ITT)？?Novs.perprotocol除了研究治療項(xiàng)目以外，其他的治療在各組間是否相同？ ? Yes兩組在治療開(kāi)始時(shí)的baseline是否相似？(Table1) ?Yes在閱讀每一篇文章時(shí)，要注意是否符合這些基本原則，如果沒(méi)有，是為什麼沒(méi)有，對(duì)於結(jié)果有沒(méi)有影響？(inMaterial&Method,Resultsection)當(dāng)有了一個(gè)可信的結(jié)果，還要考慮文章的結(jié)果對(duì)病人實(shí)際上的意義為何？重不重要(Impact重要性importance: ssiizeoofftthheeeeffffeecctt,,NNT,NNH)？文章常以RRR(Relativeriskreduction)表示療效，但以NNT(NumberNeededtoTreat),及NNH(Numberneededtoharm)表達(dá)更為直接。Yes ?

No □

?Unclear評(píng)估文章的可信度(Validity)

和實(shí)用性 (*注意研究選入病人的條件)3.CriticalAppraisaloftheEvidence(評(píng)讀批判：VIP,RAMbo,CAT,orCASPchecklist...)Criticallyappraisingtheevidenceforits(VIP)Validity(closenesstothetruth可信度)~注意文章inclusion

criteriaWastheassignmentofpatientstotreatment

randomized?Wasfollow-upofpatientssufficientlylongandcomplete?(>

80%)Wereallpatientsanalyzedintheggrroouuppsstowhichtheywererandomized?(ITT,IntensionToTreatanalysis)vs.per

protocolWerepatientsandclinicianskeptblindto

treatment?Weregroupstreatedequally,apartfromtheexperimental

therapy?Werethegroupssimilaratthestartofthe

trial?Validity(truth):considerselectionbias,informationbias,confounding

fac