如何运用实证医学资料库-快速回答临床问题
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5
搜尋實證障礙
不知道怎麼定義關鍵字
PICO, plus 同義字, MeSH Terms Filtered Resources FIRST, plus Unfiltered Resources
資源太多，不知道從何下手
不熟悉搜尋方式 只找到/看到片面現象(B)，而非貼近事實(A) (Information bias)
如何運用實證醫學資料庫 快速回答臨床問題
Quickly & Effectively
臨床人員的處境: Solution
時間有限、情況緊急: Quickly
醫療資訊太多: Effectively 醫學進步太快: Current 病人的期望: Best 缺乏Time勝於缺乏Skill在搜尋與評讀上
21
UpToDate: Result Saw palmetto brand names & quality criteria
7
Synopses: EBM Journals @ MMH Library
ACP Journal Club (P+E) Evidence Based Medicine (P+E) Bandolier (free E) Evidence-Based Cardiovascular Medicine (E) Evidence-Based Dentistry (P) Evidence-Based Eye Care (E) Evidence-Based Gastroenterology (E) Evidence-Based Health Policy & Management (E) Evidence-Based Healthcare (E) Evidence-Based Mental Health (E) Evidence-Based Obstetrics & Gynecology (E) Evidence-Based Oncology (E)
醫師為何又檢查PSA，難道有可能發生前列腺癌嗎?
朋友介紹他吃保健食品proseren，請問藥師的意見。
12
關於朋友介紹的鋸棕櫚 saw palmetto
13
PICO: 將臨床問題架構化為適當關鍵字
Question: 攝護腺肥大病人服用Saw palmetto 或 Finasteride改善泌尿道症狀的情形?
PubMed Ovid Medline
無從下手時: Meta Search、Google Search
不熟悉哪個資源可以回答這個臨床問題、慣用的資源找不到答案 但請謹慎
很多來源缺乏critical appraisal 訂購資源可能不在搜尋範圍內 只看到片面現象
Background Information / Expert Opinion
2
理想的解決方案
以最好的實證資訊，快速答覆所有的問題
把尋找證據、嚴格評讀的重擔交給研究者 與作者
臨床人員在使用實證資源時
快速（最好當下即可取得與應用） 確實能夠提供答案
3
今日節目表
認識證據等級 搜尋實證障礙 實證資源類型 PICO、關鍵字與MeSH Term 資訊檢索概念 Summaries Databases PubMed Database 動動腦時間
□Diagnosis □Therapy □Prognosis □Harm □Etiology
14
I
Intervention
C
Comparison
wk.baidu.com
O
Outcomes
Type
PICO: 將臨床問題架構化為適當關鍵字
Question: 攝護腺肥大病人服用Saw palmetto 或 Finasteride影響性功能障礙的程度
5.studies
Model from: Haynes, R. B. (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8.
1.systems
2.summaries
Filtered Resources
3.synopses
Meta Search TRIP SUMsearch
愈下層 • 文獻雜多 • 完整的關鍵字 • 費時搜尋與評讀 • 注重檢索技巧 • 資訊新穎
4.syntheses
Unfiltered Resources
8
Where to start looking for…
省力原則: 5S 由上往下
Summaries (Critically-Appraised Topics) Synopses (Critically-Appraised Individual Articles) Syntheses (Systematic Reviews) Studies (Original Papers)
UpToDate: Search
BPH
17
UpToDate: Result 症狀改善 - Saw palmetto
18
UpToDate: Result 性功能障礙 - Finasteride
19
UpToDate: Result 性功能障礙 - Saw palmetto
20
UpToDate: Result Summary and recommendations- Saw palmetto
P
Patient/Problem
BPH OR benign prostatic hyperplasia
saw palmetto OR serenoa serrulata OR serenoa repens Finasteride OR 5α-reductase inhibitor
I
Intervention
嚴格評讀原始研究 可再現(reproducible)相關決策
structured approach
定期評論與更新，確保新證據沒有被遺漏
混合個人意見和證據，而證據也常岀自reviewer個人的選擇
Unsystematic narrative review
Heneghan C, Badenoch D (2006). Evidence-based Medicine Toolkit. Haynes, RB (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8.
4
認識證據等級
證據力強 設計嚴謹 偏差少
並非所有臨床問 題都可找到最高 等級文獻，但應 盡可能使用等級 高的證據來源
證據力弱 設計薄弱 偏差多
Level 1a 1b 1c 2a 2b 2c 3a 3b 4 5
Therapy/Prevention, Aetiology/Harm Systematic review of RCTs Meta-Analysis Systematic review of RCTs ++Meta-Analysis Randomized controlled trial (RCT) Randomized controlled trial (RCT) ‘All-or-none’ Systematic review of cohort studies Cohort study or poor RCT Cohort study or poor RCT ‘Outcomes’ research ; Ecological studies Systematic review of case-control studies Case-control study Case-control study Case series Case series
E-Textbook
Drug Information
Micromedex
9
Filtered Resources (secondary)
我能相信summaries或systematic reviews嗎? 如果…
沒有利益衝突 清楚陳述問題 完整搜尋並取得相關研究
明確篩選準則，並列出參考書目
Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"
表濃縮自: Oxford Centre for EBM Levels of Evidence http://www.cebm.net/index.aspx?o=1047
11
臨床情境 1 (王瑩玉藥師贊助播出)
李先生是一位62 歲的已婚男士，育有一男一女，最 近醫師告訴他有攝護腺肥大。 醫師處方 Finasteride (proscar*) 5mg/day 建議至少給 3 – 6個月，才會改善尿流速、急尿及排尿困難。 他上網查得服藥可使攝護腺細胞不再增生，改善症狀， 但也會有性功能障礙。
C
Comparison
O
Outcomes
Sexual dysfunction OR impotence OR libido decreased
□Diagnosis □Therapy □Prognosis □Harm □Etiology
15
Type
Summaries
ACP PIER BMJ Clinical Evidence DynaMed FirstConsult UpToDate
6
5S EBM Resources
愈上層 • 資訊精萃 • 簡單的關鍵字 • 省時搜尋與評讀 • 快速支援決策 • 由下層積累
(非關證據強弱!)
連結個別病歷的臨床知識與支援決策系統
整合證據提供特定臨床問題之概述與建議 ACP PIER BMJ Clinical Evidence DynaMed FirstConsult UpToDate 對單篇研究或回顧性文獻作摘要與評述 ACP Journal Club, Evidence-Based Medicine (PubMed, Ovid Medline) 特定臨床問題的系統性評論文獻 Cochrane Database of Systematic Reviews Database of Abstracts of Reviews of Effects (PubMed, Ovid Medline): Systematic Reviews 原始文獻 (PubMed, Ovid Medline, CINAHL, EMBASE Cochrane CENTRAL, Google Scholar CEPS中文電子期刊, 中文期刊篇目索引)
10
Unfiltered Resources (primary)
何時需要搜尋 Unfiltered Resources
系統評論來自於 underpowered (small) trials Filtered resources還未處理所關注的臨床問題
Haynes, RB (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8.
P
Patient/Problem
BPH OR benign prostatic hyperplasia
saw palmetto OR serenoa serrulata OR serenoa repens Finasteride OR 5α-reductase inhibitor urinary symptoms OR urinary flow
搜尋實證障礙
不知道怎麼定義關鍵字
PICO, plus 同義字, MeSH Terms Filtered Resources FIRST, plus Unfiltered Resources
資源太多，不知道從何下手
不熟悉搜尋方式 只找到/看到片面現象(B)，而非貼近事實(A) (Information bias)
如何運用實證醫學資料庫 快速回答臨床問題
Quickly & Effectively
臨床人員的處境: Solution
時間有限、情況緊急: Quickly
醫療資訊太多: Effectively 醫學進步太快: Current 病人的期望: Best 缺乏Time勝於缺乏Skill在搜尋與評讀上
21
UpToDate: Result Saw palmetto brand names & quality criteria
7
Synopses: EBM Journals @ MMH Library
ACP Journal Club (P+E) Evidence Based Medicine (P+E) Bandolier (free E) Evidence-Based Cardiovascular Medicine (E) Evidence-Based Dentistry (P) Evidence-Based Eye Care (E) Evidence-Based Gastroenterology (E) Evidence-Based Health Policy & Management (E) Evidence-Based Healthcare (E) Evidence-Based Mental Health (E) Evidence-Based Obstetrics & Gynecology (E) Evidence-Based Oncology (E)
醫師為何又檢查PSA，難道有可能發生前列腺癌嗎?
朋友介紹他吃保健食品proseren，請問藥師的意見。
12
關於朋友介紹的鋸棕櫚 saw palmetto
13
PICO: 將臨床問題架構化為適當關鍵字
Question: 攝護腺肥大病人服用Saw palmetto 或 Finasteride改善泌尿道症狀的情形?
PubMed Ovid Medline
無從下手時: Meta Search、Google Search
不熟悉哪個資源可以回答這個臨床問題、慣用的資源找不到答案 但請謹慎
很多來源缺乏critical appraisal 訂購資源可能不在搜尋範圍內 只看到片面現象
Background Information / Expert Opinion
2
理想的解決方案
以最好的實證資訊，快速答覆所有的問題
把尋找證據、嚴格評讀的重擔交給研究者 與作者
臨床人員在使用實證資源時
快速（最好當下即可取得與應用） 確實能夠提供答案
3
今日節目表
認識證據等級 搜尋實證障礙 實證資源類型 PICO、關鍵字與MeSH Term 資訊檢索概念 Summaries Databases PubMed Database 動動腦時間
□Diagnosis □Therapy □Prognosis □Harm □Etiology
14
I
Intervention
C
Comparison
wk.baidu.com
O
Outcomes
Type
PICO: 將臨床問題架構化為適當關鍵字
Question: 攝護腺肥大病人服用Saw palmetto 或 Finasteride影響性功能障礙的程度
5.studies
Model from: Haynes, R. B. (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8.
1.systems
2.summaries
Filtered Resources
3.synopses
Meta Search TRIP SUMsearch
愈下層 • 文獻雜多 • 完整的關鍵字 • 費時搜尋與評讀 • 注重檢索技巧 • 資訊新穎
4.syntheses
Unfiltered Resources
8
Where to start looking for…
省力原則: 5S 由上往下
Summaries (Critically-Appraised Topics) Synopses (Critically-Appraised Individual Articles) Syntheses (Systematic Reviews) Studies (Original Papers)
UpToDate: Search
BPH
17
UpToDate: Result 症狀改善 - Saw palmetto
18
UpToDate: Result 性功能障礙 - Finasteride
19
UpToDate: Result 性功能障礙 - Saw palmetto
20
UpToDate: Result Summary and recommendations- Saw palmetto
P
Patient/Problem
BPH OR benign prostatic hyperplasia
saw palmetto OR serenoa serrulata OR serenoa repens Finasteride OR 5α-reductase inhibitor
I
Intervention
嚴格評讀原始研究 可再現(reproducible)相關決策
structured approach
定期評論與更新，確保新證據沒有被遺漏
混合個人意見和證據，而證據也常岀自reviewer個人的選擇
Unsystematic narrative review
Heneghan C, Badenoch D (2006). Evidence-based Medicine Toolkit. Haynes, RB (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8.
4
認識證據等級
證據力強 設計嚴謹 偏差少
並非所有臨床問 題都可找到最高 等級文獻，但應 盡可能使用等級 高的證據來源
證據力弱 設計薄弱 偏差多
Level 1a 1b 1c 2a 2b 2c 3a 3b 4 5
Therapy/Prevention, Aetiology/Harm Systematic review of RCTs Meta-Analysis Systematic review of RCTs ++Meta-Analysis Randomized controlled trial (RCT) Randomized controlled trial (RCT) ‘All-or-none’ Systematic review of cohort studies Cohort study or poor RCT Cohort study or poor RCT ‘Outcomes’ research ; Ecological studies Systematic review of case-control studies Case-control study Case-control study Case series Case series
E-Textbook
Drug Information
Micromedex
9
Filtered Resources (secondary)
我能相信summaries或systematic reviews嗎? 如果…
沒有利益衝突 清楚陳述問題 完整搜尋並取得相關研究
明確篩選準則，並列出參考書目
Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"
表濃縮自: Oxford Centre for EBM Levels of Evidence http://www.cebm.net/index.aspx?o=1047
11
臨床情境 1 (王瑩玉藥師贊助播出)
李先生是一位62 歲的已婚男士，育有一男一女，最 近醫師告訴他有攝護腺肥大。 醫師處方 Finasteride (proscar*) 5mg/day 建議至少給 3 – 6個月，才會改善尿流速、急尿及排尿困難。 他上網查得服藥可使攝護腺細胞不再增生，改善症狀， 但也會有性功能障礙。
C
Comparison
O
Outcomes
Sexual dysfunction OR impotence OR libido decreased
□Diagnosis □Therapy □Prognosis □Harm □Etiology
15
Type
Summaries
ACP PIER BMJ Clinical Evidence DynaMed FirstConsult UpToDate
6
5S EBM Resources
愈上層 • 資訊精萃 • 簡單的關鍵字 • 省時搜尋與評讀 • 快速支援決策 • 由下層積累
(非關證據強弱!)
連結個別病歷的臨床知識與支援決策系統
整合證據提供特定臨床問題之概述與建議 ACP PIER BMJ Clinical Evidence DynaMed FirstConsult UpToDate 對單篇研究或回顧性文獻作摘要與評述 ACP Journal Club, Evidence-Based Medicine (PubMed, Ovid Medline) 特定臨床問題的系統性評論文獻 Cochrane Database of Systematic Reviews Database of Abstracts of Reviews of Effects (PubMed, Ovid Medline): Systematic Reviews 原始文獻 (PubMed, Ovid Medline, CINAHL, EMBASE Cochrane CENTRAL, Google Scholar CEPS中文電子期刊, 中文期刊篇目索引)
10
Unfiltered Resources (primary)
何時需要搜尋 Unfiltered Resources
系統評論來自於 underpowered (small) trials Filtered resources還未處理所關注的臨床問題
Haynes, RB (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8.
P
Patient/Problem
BPH OR benign prostatic hyperplasia
saw palmetto OR serenoa serrulata OR serenoa repens Finasteride OR 5α-reductase inhibitor urinary symptoms OR urinary flow