精品第十屆實(shí)證醫(yī)學(xué)文獻(xiàn)查證類競(jìng)賽ppt課件

1、第十屆實(shí)證醫(yī)學(xué)文獻(xiàn)查證類競(jìng)賽組別: 進(jìn)階組參賽編號(hào): AC00061三軍總醫(yī)院陳成桃、葉爵榮、楊翔宇98.09.20臨床情境一位45歲的科技業(yè)研發(fā)工程師，任務(wù)時(shí)間很長，長期失眠且疏於運(yùn)動(dòng)。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(fā)現(xiàn)：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(jié)果無特殊發(fā)現(xiàn)。這位工程師主訴：家人都屬肥胖體質(zhì)，父親有冠狀動(dòng)脈心臟病，在65歲時(shí)植入心臟血管支架，目前規(guī)則服藥控制中。母親有高血壓、中風(fēng)及糖尿病。自已因?yàn)橥砩纤恢鼉赡陙頂嗬m(xù)

2、運(yùn)用藥物治療：睡眠障礙Stilnox 10mg HS與高脂血癥Lipitor 10mg QD。過去曾因腎結(jié)石採用ESWL治療兩次。本身沒有飲酒習(xí)慣，但壓力大時(shí)，臨床情境沒有飲酒，每週約2包。學(xué)生時(shí)代有運(yùn)動(dòng)習(xí)慣(每週跑操場(chǎng)約5公里) ，開始任務(wù)後，有空會(huì)以Wii健身，一次約30分鐘。最近半年每天平均任務(wù)時(shí)間超過14小時(shí)，每天約喝500cc黑咖啡提神，吃完宵夜，回家倒頭就睡。What are the patients concern?1 看到新聞報(bào)導(dǎo)指出，青壯年發(fā)生中風(fēng)及心肌梗塞比例逐年增高，又常感到頸部僵硬，很擔(dān)心現(xiàn)在生活習(xí)性對(duì)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

3、作用?藥物會(huì)不會(huì)造成結(jié)石?4胸悶心悸的病因?5 疾病的癒後?6高血壓、中風(fēng)及糖尿病能不能預(yù)防?7 希望可藉由自然的方式(如:改變生活型態(tài)或運(yùn)動(dòng)) 、來降低心肌梗塞的機(jī)會(huì)。8最近他在廣告上看到關(guān)於每天食用麥片取代一餐，可以有效降低膽固醇、預(yù)防心臟病的報(bào)導(dǎo)，想知道是否屬實(shí)在執(zhí)行，或者還有其它方式可能改善它目前的問題Five Steps of EBM1Asking answerable Clinical Question?2Tracking down the best Evidence3Critically Appraise Evidence4Apply to your patient5Evalua

4、tion your performance 一位45歲的科技業(yè)研發(fā)工程師，工作時(shí)間很長，長期失眠且疏於運(yùn)動(dòng)。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(fā)現(xiàn)：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(jié)果無特殊發(fā)現(xiàn)。希望可藉由自然的方式(如:改變生活型態(tài)或運(yùn)動(dòng)) 、來降低心肌梗塞的機(jī)會(huì)。Step 1. Asking answerable Clinical Question?PatientA 45-year-old man with Hyperl

5、ipidemia and have CAD high risk and R/O Metabolic syndromeInterventionDrugs therapyComparisonLife style controlOutcomePrevention AMI or CAD formation rate, MortalityPatientA 45-year-old man with Hyperlipidemia and have CAD high risk and R/O Metabolic syndromeInterventionAtrovastatin (Lipitor )Compar

6、isonOther drugs OutcomePrevention AMI or CAD formation rate, MortalityPICO type :TherapyKeywordPA 45-year-old man with Hyperlipidemia and have CAD high risk and R/O Metabolic syndromeMale, Hyperlipidemia,Metabolic syndrome,IDrugs therapyAtrovastatin , statin, HMG-COA reductase inhibitorCLife style c

7、ontrolPlacebo, diet , sports, exerciseOPrvention AMI or CAD formation rate, MortalityMortality, Treatment effect,Effectiveness, Cost-effectivenessStep 2. Tracking down the best EvidenceSearch DatabasesStudiesSynthesesPrimary databaseSecondary databaseSynopsesSummariesSystemsSearch DatabasesHyperlipi

8、demia treatmentHyperlipidemia treatmentHyperlipidemia treatment資料庫 搜尋到的篇數(shù)符和PICO篇數(shù)證據(jù)等級(jí)202SR772SR 0 0SR 182SR402SRSearching databaseDetermining Question Type ?1Therapy2Harm/Etiology3Diagnosis4Prognosis Step 3. Critical appraisal EvidenceIs the systematic review validAre the result Important?Can the re

9、sults help me?Appraising systematic reviews1Is this a systematic review of randomizedtrials?* Results of previous randomised trials have shown that interventions that lower LDL.*14 trial, Randomized, double-blind, placebo controlled, with concealed allocation.*Level: 1aYes2Does the methods section a

10、dequately 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

11、 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 designYes3Are the studies consistent, both clinically andstatistically?*The groups o

12、f patients, interventions and outcome measures were similar enough to merit combining their results.* Heterogeneity: No significantYes4Were the individual patient data used in the analysis (or aggregate data)?*SubgroupYesAre the Valid results of this systematic review important? *Measure of efficacy

13、: OR, RR *Measure the benefits and harm of the therapy: NNT, NNH *Precise are these results: 95% CIYesTreatment Better Control betterTreatment Better Control betterTreatment Better Control betterTreatment Better Control betterCan you apply this valid, important evidence from a systematic review in c

14、aring for your patient?1. Is your patient so different from those in the study that its results cannot apply?No2. Treatment feasible in your patient in your setting?Yes3. What are our patient potential benefits and harm from the therapy? (NNT, NNH)Yes4. Are our patients values and preferences satisf

15、ied by the regimen and its Consequences?Yes不同臨床決策對(duì)醫(yī)療品質(zhì)的影響傳統(tǒng)方法EBM 方法過程藉由前輩的教授及教科書的內(nèi)容來獲得答案。經(jīng)由一套有系統(tǒng)的文獻(xiàn)檢索、評(píng)估與評(píng)論過程來獲得臨床問題答案。對(duì)疾病的治療多數(shù)專家意見常有相異之處，缺乏具體的證據(jù)說服他人，因此也難以形成治療的共識(shí)。當(dāng)有清楚的證據(jù)支持某項(xiàng)治療時(shí)，就容易形成Guideline，也可以使疾病的治療更有效率。給病患貼心的建議k*zZ%FSpiqH#22S8+l(XY!PkAkA5$!%TsMCZDAKZ39-BKij$tXhSyz%Wmzxnb6dEc*aMunh8Wjpxr(jvDO0(5

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