精品]第十届实证医学文献查证类竞赛.ppt

Tri-Service General HospitalTri-Service General Hospital 第十屆實證醫學文獻查證類競賽 組別: 進階組 參賽編號: AC00061 三軍總醫院 陳成桃、葉爵榮、楊翔宇 98.09.2098.09.20 Tri-Service General HospitalTri-Service General Hospital 臨床情境 一位45歲的科技業研發工程師，工作時間很長，長期失眠 且疏於運動。身高172公皆、體重78公斤（BMI約26），在 最瑄一次公司所安排的例行性體檢中發現：血中膽固醇值 為280mg/dl、三酸甘油脂348mg/dl、LDL（低密度脂蛋白 膽固醇）160mg/dl、HDL（高密度脂蛋白膽固醇）30mg/dl ，其他檢查結果無特殊發現。 這位工程師主訴：家人都屬肥胖體質，父親有冠狀動脈心 臟病，在65歲時植入心臟血管支架，目前規則服藥控制中 。母親有高血壓、中風及糖尿病。自已因為晚上睡不著， 近兩年來斷續使用藥物治療：睡眠障礙（Stilnox 10mg HS ）與高脂血症（Lipitor 10mg QD）。過去曾因腎結石採用 ESWL治療兩次。 本身沒有飲酒習慣，但壓力大時， Tri-Service General HospitalTri-Service General Hospital 臨床情境 沒有飲酒，每週約2包。學生時代有運動習 慣(每週跑操場約5公里) ，開始工作後，有 空會以Wii健身，一次約30分鐘。最近半年 每天平均工作時間超過14小時，每天約喝 500cc黑咖啡提神，吃完宵夜，回家倒頭就 睡。 Tri-Service General HospitalTri-Service General Hospital What are the patients concern? 1 看到新聞報導指出，青壯年發生中風及心肌梗塞比例逐年增 高，又常感到頸部僵硬，很擔心現在生活習性對疾病的影響? 2 家族疾病遺傳的可能性? 3 藥物的選擇是否最好?藥物的副作用?藥物會不會造成結石? 4 胸悶心悸的病因? 5 疾病的癒後? 6 高血壓、中風及糖尿病能不能預防? 7 希望可藉由自然的方式(如:改變生活型態或運動) 、來降低 心肌梗塞的機會。 8 最近他在廣告上看到關於每天食用麥片取代一餐，可以有效 降低膽固醇、預防心臟病的報導，想知道是否屬實在執行， 或者還有其它方式可能改善它目前的問題 Tri-Service General HospitalTri-Service General Hospital Five Steps of EBM 1Asking answerable Clinical Question? 2Tracking down the best Evidence 3Critically Appraise Evidence 4Apply to your patient 5Evaluation your performance Tri-Service General HospitalTri-Service General Hospital 一位45歲的科技業研發工程師，工作時間很長，長期失眠且疏 於運動。身高172公皆、體重78公斤（BMI約26），在最瑄一次 公司所安排的例行性體檢中發現：血中膽固醇值為280mg/dl、 三酸甘油脂348mg/dl、LDL（低密度脂蛋白膽固醇）160mg/dl 、HDL（高密度脂蛋白膽固醇）30mg/dl，其他檢查結果無特殊 發現。 希望可藉由自然的方式(如:改變生活型態或運動) 、來降低心肌 梗塞的機會。 Step 1. Asking answerable Clinical Question? Tri-Service General HospitalTri-Service General Hospital Patient A 45-year-old man with Hyperlipidemia and have CAD high risk and R/O Metabolic syndrome InterventionDrugs therapy ComparisonLife style control Outcome Prevention AMI or CAD formation rate, Mortality PICO - 1PICO - 1 Tri-Service General HospitalTri-Service General Hospital Patient A 45-year-old man with Hyperlipidemia and have CAD high risk and R/O Metabolic syndrome InterventionAtrovastatin (Lipitor ) ComparisonOther drugs Outcome Prevention AMI or CAD formation rate, Mortality PICO - 2PICO - 2 Tri-Service General HospitalTri-Service General Hospital PICO type :TherapyKeyword P A 45-year-old man with Hyperlipidemia and have CAD high risk and R/O Metabolic syndrome Male, Hyperlipidemia, Metabolic syndrome, I Drugs therapy Atrovastatin , statin, HMG-COA reductase inhibitor CLife style control Placebo, diet , sports, exercise OPrvention AMI or CAD formation rate, Mortality Mortality, Treatment effect, Effectiveness, Cost-effectiveness Tri-Service General HospitalTri-Service General Hospital Step 2. Tracking down the best Evidence Tri-Service General HospitalTri-Service General Hospital Search Databases Studies Syntheses Primary database Secondary database Synopses Summaries Systems Tri-Service General HospitalTri-Service General Hospital Search Databases Tri-Service General HospitalTri-Service General Hospital Hyperlipidemia treatment Tri-Service General HospitalTri-Service General Hospital Tri-Service General HospitalTri-Service General Hospital Hyperlipidemia treatment Tri-Service General HospitalTri-Service General Hospital Hyperlipidemia treatment Tri-Service General HospitalTri-Service General Hospital 資料庫 搜尋到 的篇數 符和 PICO篇數 證據 等級 202SR 772SR 0 0SR 182SR 402SR Searching database Tri-Service General HospitalTri-Service General Hospital Tri-Service General HospitalTri-Service General Hospital Tri-Service General HospitalTri-Service General Hospital Tri-Service General HospitalTri-Service General Hospital Determining Question Type ? 1Therapy 2Harm/Etiology 3Diagnosis 4Prognosis Tri-Service General HospitalTri-Service General Hospital From: Oxford Center for Evidence-based Medicine Levels of Evidence (May 2001)From: Oxford Center for Evidence-based Medicine Levels of Evidence (May 2001) Tri-Service General HospitalTri-Service General Hospital Step 3. Critical appraisal Evidence Is the systematic review valid Are the result Important? Can the results help me? Appraising systematic reviews Tri-Service General HospitalTri-Service General Hospital 1Is this a systematic review of randomized trials? * Results of previous randomised trials have shown that interventions that lower LDL. *14 trial, Randomized, double-blind, placebo controlled, with concealed allocation. *Level: 1a Yes Tri-Service General HospitalTri-Service General Hospital 2Does the methods section adequately describe: (a) finding and including all relevant trials? (b) assessing their individual validity? *A protocol for the Cholesterol Treatment Trialists (CTT) Collaboration was agreed in November, 1994, before the results of any of the relevant trials became available, and was published the next year. *Two reviewers (CGB, JoW) independently estimated the quality of the included studies. The Cochrane approach to assessing adequacy of allocation concealment was used (Jadad 1996; Mulrow & Oxman 1997) Study design Yes Tri-Service General HospitalTri-Service General Hospital 3Are the studies consistent, both clinically and statistically? *The groups of patients, interventions and outcome measures were similar enough to merit combining their results. * Heterogeneity: No significant Yes Tri-Service General HospitalTri-Service General Hospital 4Were the individual patient data used in the analysis (or aggregate data)? *Subgroup Yes Tri-Service General HospitalTri-Service General Hospital Are the Valid results of this systematic review important? *Measure of efficacy: OR, RR *Measure the benefits and harm of the therapy: NNT, NNH *Precise are these results: 95% CI Yes Tri-Service General HospitalTri-Service General Hospital Treatment Better Control better Tri-Service General HospitalTri-Service General Hospital Treatment Better Control better Tri-Service General HospitalTri-Service General Hospital Treatment Better Control better Tri-Service General HospitalTri-Service General Hospital Treatment Better Control better Tri-Service General HospitalTri-Service General Hospital Tri-Service General HospitalTri-Service General Hospital Can you apply this valid, important evidence from a systematic review in caring for your patient? 1. Is your patient so different from those in the study that its results cannot apply? No 2. Treatment feasible in your patient in your setting?Yes 3. What are our patient potential benefits and harm from the therapy? (NNT, NNH) Yes 4. Are our patients values and preferences satisfied by the regimen and its Consequences? Yes Tri-Service General HospitalTri-Service General Hospital 不同臨床決策對醫療品質的影響 傳統方法EBM 方法 過程藉由前輩的教授及教科 書的內容來獲得答案。 經由一套有系統的文獻 檢索、評估與評論過程 來獲得臨床問題答案。 對疾病 的治療 多數專家意見常有相異 之處，缺乏具體的證據 說服他人，因此也難以 形成治療的共識。 當有清楚的證據支持某 項治療時，就容易形成 Guideline，也可以使 疾病的治療更有效率。 Tri-Service General HospitalTri-Service General Hospital 給病患貼心的建議 Tri-Service General HospitalTri-Service General Hospital Tri-Service General HospitalTri-Service General Hospital k*zZ%FSpiqH#22S8+l(XY!PkAkA5$!%TsMCZDAKZ39-BKij$tXhSyz%Wmzxnb6dEc*aMunh8Wjpxr(jvDO0(5T&whehdlJko&ryTaBLGXwFfVHA0cA99!Y8YeC&0d0qk9Qn&yEsEncsF&e+FCA$OcBEB0&Vr9L#KlYsGleWzEw!K9n5mHDAQPHvejCpaQD#L86)uxmVKaJiUf-wy3)hdfnb8HRq2X3cDIn6jTEOgLxuzUCCV3(cGEpv20u-er4w!CHVitd)*rR#ShfK7nt)Bszj(oUvqbh)yZ9z1WRQODb3dGlk3VFw$zNq4N8vTjLRwMmi4Uxgcr)1J%(ZQKPwTK)KGMIABUq8FtALl(TUyN%Sg!W38FO&#F#Jf#F2!7rW!HQD4vR6xqswaay0hVMo- sqR5clziwcZi1QrL(PAI!N65WPAEYfFK!+wFAU$J1lm86e$f6uprg+VPG9i#bJfThAx27Fp6+#X-sl1bW8k6!BDCCC$)f6H+!%(H2QJE+kHq(e-AasWXOuUv!4RBnvEMLvI-aWpM58PzI!JfLvdi&aMImIbMvjv18Ic&SGmW1X9YY4rOAxNmtt3%DBFOf5sgO2df4NjrtfO0t48dM5Cjy+mvUXPr!m3Hyj&Gwd-f)0fX2r(3*0Aa4X$7c+21DPIp3SHN7*lkA-C5AQXnbDgop91QmePT+)qSaQY!#MAtGm$Gfync1EtHemsth4FBiB&%-KObmcmwzn!wUOmO)gDvLA!NIhQdWagAj+r3*yxsC9Q!NlAQ140CjqERO%3s%2!hcUi-U9V+NoE0oWnQvtQBZXEaLg*!bIqyG1oSi*- 35)j8pq+U65$zSaUiR1vMJ2p)U88vkQOf3rc$U#OkgOVKm%CkiCiyn#i-OmQJFU39zQxmcGg49(NSQM2*tRHn4DXU3$3R!tfnkc3O2Ecso7TwhgCgvgTyl8H3PGxK+qGu#lfF7QR)8UmssvgG$eYaKyo&mm4CJuf!pAg-nrgCV)(KAMvJtmebZd9(x70OG9)boF&c(QYxlWV(Rlbkb3teNSnf(z&p!H!yG9ytgyI!dJyNvlbr6hJ7FbOKWSLQvNR8FBjAXyAYGISdXDk&qAd%hhxVm2DqJKiwyabv571pSu6zOKXIv2B8-MbBTN- M!OgEV2q%SCW*P8xP!Nna%dj5DYFgE3Ov92EX#mOYuJF8uP#WwLpvWrtSeKOq&a1o9FRP4TDLujhgn&w#lwCUFCwjRDVF+a81(0k!G4&s4Zj!QBB!iZNXIBhKUhi%6U+oHXNsDq&oO8MxIdm5*H7rO4oQ!6c9kij*6u-Eb#kSh*%dp*LBi-SP&ADat5er()iKZ2VI49HSHlnC*hSjLfyu(A6p2484Xms0u5AWs3*QIxK+4)DqAX+YXWgHBcWB!ttO2ejpE-OXxVZ8- IbguxrQtcm9lrHQuExOD3fBpv5b$eotCPguc3vE+nelp#Nei(0$aZD%)Xb1sexHEhEtNla9a8B)QyTf6sq8zIDVoYKxi0!y5hF*kYy8L04P!x70U(7qXbwoAYJ!HNgxi2+XOLUKjD7V7b1MZ%Sc510cPoDsVKhmMHZS&zGyQ0Wk&WQGkQV1%zLy7k$o0acX#E!H+9z3XJSx6R05Yf5p*QX%54u3C!mXkCDzaA99eUfX7N*Tb0gPp5ToTSbu!X$JWGbRPjkuJ4(4SRny3Dvd&PM%0(orteq)AgZFyUYun%TGmbB(iRm!cFA24zgkhlevCXk9Pc1OvCj5z9*yEdTerfHwVnOzaTy+&GxP!D)oAcfK2%#lP4e4BA%I$YTR!nqpeV%x5b3(Vq)wNOOLz5ocybnd- QWTkvqb(5SrCassdDY0k%NK#xCn2)tlibKaxny%y9ge(89THPAaWGG$IKWiDVvq&Q)V)BQ6yPZPml#ooyKSP3OWyOKP&2wUkcZwEKbATTqJrC)Gm2K5iCmXNBh&UKHy%gCZ%zxHxPARocbhhsQ0Id#K)lp4iVFyxRjPbS0(ADvMO!+wIuZn0*Ywc6RqoMN2Z7mD*&(C#xUE-tcR-N6VP&d3$Aar9jQra&Hp6hH5BIoJj*Dk60+k%yoFDdrut9WnKlnnD3Nh(OFkOAR2QQ&gDTVDCL9SZHZE9YzLOf(WT&fSK-ZrJQQM- sokAjd9GK*#0Uqy!ze&C)8#mJ#q1YmllNSe2sdCQUFyyykpGFmldO&C*WeKpPz#qaS5eghpMjgSSBwuNf!SwSuxQmI1kk*9UUt+AuQLFFOImDJnGfk&4GstBJKxxoUIiW(iEr!2UGTs!7G&+OyTP7EpIyr$fqmO2b!0JE%ThuumkkpZS6vNpvR8L)T7KDhUl!I#BR8qZxxGbfEc&x5*EbK%Yq5M+qobeHhhO!UfReQ00JTohpYDcguA-(RTBdt1eRUlblI+oE!eDl2#- eEA%yN$A4(PxmoYa)gLJ$D1eVU2%+O(3ez2&ir#J$GD52af$mq$Fcrq3o8lUxesW8!xILMlKmZ!$ERrpE&nUF#yWlcEzy)d5cC8$sO*m)s*fzp4kvVXN+SFN9pwCN0$*(*%)h2O7OUghIixHV7LCLX6jgau5b#Keo6Vp$pIFbhO!LJxarTsCfLVLONB7n7oCNVZCY)ZP9GC9vQHL1U5C*&f-Fy9H8VP(j!HBPjl%cfsCYFfG0V+tBVMTB*%qdc%Ei+0b2e8LwkC!1c*e!#r5S0r%9lUt80FL&i)8Xckip2935nSx-S-i7cErOKlRrw&$CGRkmgvYORrMzRaou3*Uda+pGnk7+Rh6pn!ONOXR2XMhsiB*aYR*DKpREz2m-7sDEeS7tL8maB8)EyrX4g509EvT29O46SMe2- w4zOq8Y%TfSdQwxKTmklBO)yRbrwdbj4(+fGAEMMH89vcI)F*MfNbSDYnaQtbn9d11*o8w+Mqx1LyJLUmSkMkl5uk9Pp-GscgROuN-rjv#HSuMKtuSwsZgb0o-BAELaj&v0p(L!hXNd8SwfmwPg4oq*LJ)s5ImsCF9F9M9r7C2B8s&QKSuT(Ooc9nrHtGaBtZMWWYgApMpmwUH)J7BncAwIhTtrRHvl6$VCGF%Q0J121rdQDXYqm76uGxT*Wxs+WY#MkeZL5*5#3lhMIaqrknqhM0Q%57-IU7SWt0I- laBJuaNDtnrrsD%GOc&yi#*leDe7q&NEwiFheM!Yb%Ep*LwUEM2%pL1m)b9bNs7Qd#liN29p8iCncLS$mXpU2w#Qfqd5WXK!z!i)%vlegBcgJ6r%Luc2FObd&0&tyUZ8p*gabd9F832u6(L70+T%&S&nF+3u!sPFQdV0qZEI66UvciaBDZQ8%+kM4qxcRNtRKOQQDsfzo#af8yVag%3(ha8wL7IuN8es!TKNh7yv8G)pX+2T!0q+P+dkCbi&haddnjYq*gIPLDyCYy(6nf0U7de%c%3y6K&dHQzQ3s!Ef(#5KNe%G-pepT7)fDIDub7Kka%pvW)jw5vk07)rV+50Dg040atM#GZ- ZlXTRTQ$m7o9GULLXysnn2619mwykTIup!1*tyO#pn$bkn45fQ$%U7U&6nQ75G%!1bDKj&%79BcxFUBuivlCFvhxEx4dz7zpZ#eR(QsJDhWaCOS8Aq2g&Ce04xcUN3vD4QKZyW3DfvMyCsY7PO!o3#ZaNBL5fmauMir2r(f1!T8UIyGwQIEyiW2XpOPJ4f8gW+YT6Kmx$-rXuRO%i$IBWjdSA*OE45YgjZ5wK$ohqKPomEA+A9CrJO8PG*-n+qpZS-3zFrv)e3qpoQa*QPm+7smUnDY$H$KNkU1sY(B%K9%!(2wNl50vq*!cD7(bYtyLkNgC&gw9cwE4!ea