臨床案例 介紹 與 應用  2007 Jul/25 基隆長庚.楊宗翰醫師 實證醫學中心 風濕過敏免疫科
Five Steps <ul><li>Ask </li></ul><ul><li>Acquire (Search) </li></ul><ul><li>Appraise </li></ul><ul><li>Apply </li></ul><ul...
Appraise <ul><li>Valid, Impact, Practical </li></ul><ul><li>Appraised by  yourself  … </li></ul><ul><ul><li>Time consuming...
查
Best Solution! <ul><li>定期更新 </li></ul><ul><li>資料來源 </li></ul><ul><li>簡單易用 </li></ul><ul><li>更好 </li></ul><ul><li>更聰明 </li>...
148  個選擇
36  個選擇
推薦六個
One
Acquire - Which & Why? <ul><li>Contents </li></ul><ul><li>How to search? </li></ul><ul><li>Results of search? </li></ul><u...
Acquire - Which & Why? <ul><li>Contents  (original, EBM review, review) </li></ul><ul><li>How to search? </li></ul><ul><ul...
Contents <ul><li>Original articles </li></ul><ul><ul><li>Medline (citation) </li></ul></ul><ul><ul><li>Core clinical journ...
All in One <ul><li>Systems </li></ul><ul><ul><li>MD Consult </li></ul></ul><ul><ul><li>Clinical Resources @ OVID </li></ul...
Benchmark! … Patient education, … More Traditional, semantic … Smarter, Easier, Better Search & Result Books ($, 61) Textb...
Case 1 Diagnosis & Screening
 
Ask <ul><li>Case Summary: 56 year-old man, without smoking, drinking, hepatitis and no family history of cancer </li></ul>...
Acquire / Search 2004
Result <ul><li>Journals / MEDLINE & The Clinics </li></ul><ul><ul><li>Principles of cancer screening  </li></ul></ul><ul><...
Journals / MEDLINE  Principles of cancer screening
Textbooks Abeloff: Clinical Oncology
Patient Education Cancer, Screening for 
 
Apply & Summary <ul><li>Lung cancer </li></ul><ul><li>Stomach cancer </li></ul><ul><li>Colorectal cancer </li></ul><ul><ul...
Summary <ul><li>要不要做癌症篩檢? 要篩檢那些項目? </li></ul><ul><li>Content – Reviews </li></ul><ul><ul><li>Books </li></ul></ul><ul><ul>...
Case 2 Etiology & Prevention
 
Ask <ul><li>P: healthy adult </li></ul><ul><li>I: HP+ </li></ul><ul><li>C: HP- </li></ul><ul><li>O: gastric cancer risk </...
Acquire / Search 2006
1
2
 
3
Appraisal – Result <ul><li>HP & gastric cancer risk </li></ul><ul><li>Type of Question: </li></ul><ul><ul><li>Etiology </l...
 
 
4
<ul><li>Appraisal - PICOT:  H. pylori  eradication does not reduce gastric cancer incidence in a high-risk area of China <...
Appraisal – Study Design (RCT) <ul><li>Population </li></ul><ul><ul><li>Changle Public Health Bureau, Fujian Province , so...
Population P Outcomes:  Gastric cancer O Randomised Controlled Trial Time: 7.5 yrs T Randomized allocation I C Interventio...
Appraisal – Result subgroup precancerous lesions 0.02 6 0 No NS 5 7 Yes 0.33 204 11/813 1.35% 7/817 0.86% Gastric cancer p...
Summary <ul><li>Is HP infection a risk of gastric cancer </li></ul><ul><ul><li>Level I evidence </li></ul></ul><ul><ul><li...
Summary <ul><li>HP  是不是胃癌的危險因子? 治療  HP  是否能減少胃癌? </li></ul><ul><li>Content –  </li></ul><ul><ul><li>Books, Clinics (Review...
Case 3 Therapy
Case 3 <ul><li>張小妹,五歲,喜歡吃糖但卻滿口蛀口。 </li></ul>
Ask <ul><li>P: children/adults with dental caries </li></ul><ul><li>I: chewing gum with xylitol </li></ul><ul><li>C: chewi...
Acquire / Search
Results - Clinics
<ul><li>Appraisal - PICOT: </li></ul><ul><ul><ul><ul><ul><li>P articipants: young adult </li></ul></ul></ul></ul></ul><ul>...
Results – Clinics/Guidelines
<ul><li>Appraisal - PICOT: </li></ul><ul><li>P articipants: 169 mother-child pairs </li></ul><ul><li>I ntervention:  xylit...
Appraisal – Result 48.5% 28.6% 9.7% Children detectable @ age 2 After 3-6 years Rate of caries Mother High High High C (33...
Apply
Summary <ul><li>Xylitol  能不能減少蛀牙? </li></ul><ul><li>Content –  </li></ul><ul><ul><li>Clinics (Review) </li></ul></ul><ul><...
Benchmarks <ul><li>[email_address] </li></ul><ul><ul><li>多.雜 </li></ul></ul><ul><ul><li>Journal  </li></ul></ul><ul><ul><u...
One
 
Summary <ul><li>How to select database </li></ul><ul><ul><li>Content (original, EBM review, review) </li></ul></ul><ul><ul...
Summary <ul><li>Contents  (original, EBM review, review) </li></ul><ul><li>How to search? </li></ul><ul><ul><li>Keywords O...
MD Consult <ul><li>Smarter, Easier & Better </li></ul><ul><li>One of the  Best  for  background questions </li></ul><ul><l...
Suggestions for MD Consult <ul><li>Duplicated results in Journals & Clinics </li></ul><ul><li>Textbooks with publication y...
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MD Consult 改版說明會 - 實證醫學 – 資料庫使用與臨床實作

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MD Consult 改版說明會 - 實證醫學 – 資料庫使用與臨床實作 - 楊宗翰醫師

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MD Consult 改版說明會 - 實證醫學 – 資料庫使用與臨床實作

  1. 1. 臨床案例 介紹 與 應用 2007 Jul/25 基隆長庚.楊宗翰醫師 實證醫學中心 風濕過敏免疫科
  2. 2. Five Steps <ul><li>Ask </li></ul><ul><li>Acquire (Search) </li></ul><ul><li>Appraise </li></ul><ul><li>Apply </li></ul><ul><li>Audit </li></ul><ul><li>問 </li></ul><ul><li>查 </li></ul><ul><li>讀 </li></ul><ul><li>用 </li></ul><ul><li>審 </li></ul>
  3. 3. Appraise <ul><li>Valid, Impact, Practical </li></ul><ul><li>Appraised by yourself … </li></ul><ul><ul><li>Time consuming </li></ul></ul><ul><li>Appraised by authorized specialists </li></ul><ul><ul><li>Systems, Synopses, Synthesis </li></ul></ul>
  4. 4.
  5. 5. Best Solution! <ul><li>定期更新 </li></ul><ul><li>資料來源 </li></ul><ul><li>簡單易用 </li></ul><ul><li>更好 </li></ul><ul><li>更聰明 </li></ul><ul><li>更簡單 </li></ul>
  6. 6. 148 個選擇
  7. 7. 36 個選擇
  8. 8. 推薦六個
  9. 9. One
  10. 10. Acquire - Which & Why? <ul><li>Contents </li></ul><ul><li>How to search? </li></ul><ul><li>Results of search? </li></ul><ul><li>Google </li></ul><ul><li>MSN </li></ul><ul><li>Yahoo </li></ul>
  11. 11. Acquire - Which & Why? <ul><li>Contents (original, EBM review, review) </li></ul><ul><li>How to search? </li></ul><ul><ul><li>Keywords OR thesaurus/MeSH </li></ul></ul><ul><ul><ul><li>Synonymy/acronym </li></ul></ul></ul><ul><ul><ul><li>Query interpretation (heart attack cancer) </li></ul></ul></ul><ul><ul><li>Search strategy </li></ul></ul><ul><ul><ul><li>Boolean logics (AND/OR/NOT/NEAR) </li></ul></ul></ul><ul><ul><ul><li>Categories & filters (quality & publication types) </li></ul></ul></ul><ul><ul><li>Search refinements </li></ul></ul><ul><ul><ul><li>Diagnosis, Differential diagnosis, etiology, pathogenesis, prognosis, signs, symptoms, treatment </li></ul></ul></ul><ul><ul><ul><li>Population, disease entity (hypertension – pregnancy, portal, pulmonary, renal…) </li></ul></ul></ul><ul><li>Results of search? </li></ul><ul><ul><li>Numbers of results – sensitive or specific </li></ul></ul><ul><ul><li>The order of results – time (current), relevant (best?), clinically appropriate (definition?) </li></ul></ul>
  12. 12. Contents <ul><li>Original articles </li></ul><ul><ul><li>Medline (citation) </li></ul></ul><ul><ul><li>Core clinical journals (full text) </li></ul></ul><ul><li>EBM reviews </li></ul><ul><ul><li>Systematic reviews … </li></ul></ul><ul><ul><li>Guidelines </li></ul></ul><ul><li>Reviews </li></ul><ul><ul><li>Textbooks </li></ul></ul><ul><ul><li>Review articles </li></ul></ul><ul><li>更新頻率 </li></ul><ul><li>Cochrane library </li></ul><ul><li>Clinical Evidences </li></ul><ul><li>Uptodate </li></ul><ul><li>ACP medicine & PIER </li></ul><ul><li>[email_address] </li></ul>
  13. 13. All in One <ul><li>Systems </li></ul><ul><ul><li>MD Consult </li></ul></ul><ul><ul><li>Clinical Resources @ OVID </li></ul></ul>
  14. 14. Benchmark! … Patient education, … More Traditional, semantic … Smarter, Easier, Better Search & Result Books ($, 61) Textbook ( 51 ) Review (Clinics – 35 ) Reviews All EBMR (Cochrane, DARE, ACP …) Guidelines EBM reviews Medline & CINAHL Full text ($) Medline Core Journals ( 53 ) Original articles [email_address] MD Consult Contents
  15. 15. Case 1 Diagnosis & Screening
  16. 17. Ask <ul><li>Case Summary: 56 year-old man, without smoking, drinking, hepatitis and no family history of cancer </li></ul><ul><li>P: aged adult </li></ul><ul><li>I: screening </li></ul><ul><li>C: not screening </li></ul><ul><li>O: benefit on survival </li></ul><ul><li>Type of Question: screening, diagnosis </li></ul><ul><li>Keyword: cancer screening </li></ul>
  17. 18. Acquire / Search 2004
  18. 19. Result <ul><li>Journals / MEDLINE & The Clinics </li></ul><ul><ul><li>Principles of cancer screening </li></ul></ul><ul><li>Textbooks </li></ul><ul><ul><li>Abeloff: Clinical Oncology  - 69 Results </li></ul></ul><ul><li>Patient Education </li></ul><ul><ul><li>Cancer, Screening for  </li></ul></ul>
  19. 20. Journals / MEDLINE Principles of cancer screening
  20. 21. Textbooks Abeloff: Clinical Oncology
  21. 22. Patient Education Cancer, Screening for 
  22. 24. Apply & Summary <ul><li>Lung cancer </li></ul><ul><li>Stomach cancer </li></ul><ul><li>Colorectal cancer </li></ul><ul><ul><li>> 50 year-old </li></ul></ul><ul><ul><li>Fecal occult blood </li></ul></ul><ul><ul><li>Sigmoidoscopy (colonoscopy) </li></ul></ul><ul><li>Prostate cancer </li></ul><ul><ul><li>PSA or digital rectal examination </li></ul></ul>
  23. 25. Summary <ul><li>要不要做癌症篩檢? 要篩檢那些項目? </li></ul><ul><li>Content – Reviews </li></ul><ul><ul><li>Books </li></ul></ul><ul><ul><li>Medline, Clinics </li></ul></ul><ul><ul><li>Patient Education </li></ul></ul>
  24. 26. Case 2 Etiology & Prevention
  25. 28. Ask <ul><li>P: healthy adult </li></ul><ul><li>I: HP+ </li></ul><ul><li>C: HP- </li></ul><ul><li>O: gastric cancer risk </li></ul><ul><li>Type of Question: </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><li>P: patient with HP </li></ul><ul><li>I: HP eradication </li></ul><ul><li>C: not eradication </li></ul><ul><li>O: gastric cancer risk </li></ul><ul><li>Type of Question: </li></ul><ul><ul><li>Treatment / Prevention </li></ul></ul><ul><li>Case Summary: </li></ul><ul><ul><li>Is HP infection a risk of gastric cancer </li></ul></ul><ul><ul><li>Is HP eradication decrease risk of gastric cancer </li></ul></ul>
  26. 29. Acquire / Search 2006
  27. 30. 1
  28. 31. 2
  29. 33. 3
  30. 34. Appraisal – Result <ul><li>HP & gastric cancer risk </li></ul><ul><li>Type of Question: </li></ul><ul><ul><li>Etiology </li></ul></ul><ul><li>Level I evidence ( meta-analysis of 19 cohort or case-controlled studies with age- and sex-matched controls) </li></ul><ul><li>OR for HP & cancer </li></ul><ul><ul><li>Overall 1.92 (1.32-2.78) </li></ul></ul><ul><ul><li>Cohort 2.24 (1.15-4.4) </li></ul></ul><ul><ul><li>Case-Control 1.81 (1.16-2.84) </li></ul></ul>
  31. 37. 4
  32. 38. <ul><li>Appraisal - PICOT: H. pylori eradication does not reduce gastric cancer incidence in a high-risk area of China </li></ul><ul><ul><ul><ul><ul><li>P articipants: 1630 healthy carriers of H. pylori infection in China </li></ul></ul></ul></ul></ul><ul><li>2. I ntervention: H. pylori eradication </li></ul><ul><li>3. C omparison: placebo </li></ul><ul><li>4. O utcome: incidence of gastric cancer </li></ul><ul><li>5. T imeframe: 7.5 years of follow-up </li></ul>
  33. 39. Appraisal – Study Design (RCT) <ul><li>Population </li></ul><ul><ul><li>Changle Public Health Bureau, Fujian Province , southern China (a high risk area for gastric cancer); July 1994 to December 2001. </li></ul></ul><ul><ul><li>? cases screened; ? eligible; 1630 enrolled </li></ul></ul><ul><li>Inclusion: </li></ul><ul><ul><li>positive for H. pylori; normal endoscopy; </li></ul></ul><ul><ul><li>aged between 35 and 65 years </li></ul></ul><ul><li>Exclude: </li></ul><ul><ul><li>severe illness; endoscopic ulcers </li></ul></ul><ul><ul><li>history of H. pylori eradication treatment. </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>a 2-week course of twice daily omeprazole 20 mg, combined amoxilcillin and clavulanate potassium 750 mg plus metronidazole 400 mg (n=817); or placebo (n =813). </li></ul></ul><ul><ul><li>If active treatment failed to treat infection, quadruple therapy was instigated at 6 weeks for 1 week (colloidal bismuth subcitrate 240 mg, metronidazole 600 mg, clarithromycin 500 mg and omeprazole 20 mg all twice daily). </li></ul></ul><ul><li>Blinded follow up for H. pylori infection was carried out every 6 months thereafter for 7.5 years with endoscopic examination at 5 years for 62% of participants. </li></ul>
  34. 40. Population P Outcomes: Gastric cancer O Randomised Controlled Trial Time: 7.5 yrs T Randomized allocation I C Intervention: anti-HP Control: placebo © EBHC 2004;8:218–220 JAMA 2004;291:187–194.
  35. 41. Appraisal – Result subgroup precancerous lesions 0.02 6 0 No NS 5 7 Yes 0.33 204 11/813 1.35% 7/817 0.86% Gastric cancer p-value NNT C n=813 I n=817 Outcome
  36. 42. Summary <ul><li>Is HP infection a risk of gastric cancer </li></ul><ul><ul><li>Level I evidence </li></ul></ul><ul><ul><li>Yes </li></ul></ul><ul><ul><li>About 2x </li></ul></ul><ul><li>Is HP eradication decrease risk of gastric cancer </li></ul><ul><ul><li>Level II evidence </li></ul></ul><ul><ul><li>No or uncertain </li></ul></ul>
  37. 43. Summary <ul><li>HP 是不是胃癌的危險因子? 治療 HP 是否能減少胃癌? </li></ul><ul><li>Content – </li></ul><ul><ul><li>Books, Clinics (Review) </li></ul></ul><ul><ul><li>Medline (EBM Review) </li></ul></ul>
  38. 44. Case 3 Therapy
  39. 45. Case 3 <ul><li>張小妹,五歲,喜歡吃糖但卻滿口蛀口。 </li></ul>
  40. 46. Ask <ul><li>P: children/adults with dental caries </li></ul><ul><li>I: chewing gum with xylitol </li></ul><ul><li>C: chewing gum without xylitol </li></ul><ul><li>O: incidence of dental decay </li></ul><ul><li>Type of Question: therapy </li></ul><ul><li>Keyword: </li></ul><ul><ul><li>Dental caries </li></ul></ul><ul><ul><li>xylitol </li></ul></ul>
  41. 47. Acquire / Search
  42. 48. Results - Clinics
  43. 49. <ul><li>Appraisal - PICOT: </li></ul><ul><ul><ul><ul><ul><li>P articipants: young adult </li></ul></ul></ul></ul></ul><ul><li>2. I ntervention: 6-7 g of xylitol gum/day </li></ul><ul><li>3. C omparison: 6-7 g of sucrose gum/day </li></ul><ul><li>4. O utcome: 80% v caries increment </li></ul><ul><li>5. T imeframe: 1 year </li></ul><ul><li>? Xylitol vs. no </li></ul>
  44. 50. Results – Clinics/Guidelines
  45. 51. <ul><li>Appraisal - PICOT: </li></ul><ul><li>P articipants: 169 mother-child pairs </li></ul><ul><li>I ntervention: xylitol (106) </li></ul><ul><li>C omparison: chlorhexidine or fluroride (30 or 33) </li></ul><ul><li>O utcome: rate of caries in child </li></ul><ul><li>T imeframe: 2 year </li></ul><ul><li>Protocol: </li></ul><ul><li>Xylitol >65% xylitol/weight of gum </li></ul><ul><li>xylitol gum chewing - 2-3/d, started 3 mo after delivery </li></ul><ul><li>Varnish treatment – 6, 12, & months after delivery </li></ul>
  46. 52. Appraisal – Result 48.5% 28.6% 9.7% Children detectable @ age 2 After 3-6 years Rate of caries Mother High High High C (33) fluoride C (30) chlorhexidine I (106) xylitol Salivary mutans streptococci levels
  47. 53. Apply
  48. 54. Summary <ul><li>Xylitol 能不能減少蛀牙? </li></ul><ul><li>Content – </li></ul><ul><ul><li>Clinics (Review) </li></ul></ul><ul><ul><li>Guidelines (EBM Review) </li></ul></ul>
  49. 55. Benchmarks <ul><li>[email_address] </li></ul><ul><ul><li>多.雜 </li></ul></ul><ul><ul><li>Journal </li></ul></ul><ul><ul><ul><li>Abstract </li></ul></ul></ul><ul><ul><li>Order </li></ul></ul><ul><ul><ul><li>Not optimized </li></ul></ul></ul><ul><li>Uptodate </li></ul><ul><ul><li>1 sentence </li></ul></ul><ul><li>ACP med/pier – 0 </li></ul><ul><li>Clinical evidence - 0 </li></ul><ul><li>Medline Hand Search </li></ul><ul><ul><li>Meta analysis - 0 </li></ul></ul><ul><ul><li>therapy optimized - 42 </li></ul></ul>
  50. 56. One
  51. 58. Summary <ul><li>How to select database </li></ul><ul><ul><li>Content (original, EBM review, review) </li></ul></ul><ul><ul><li>Search strategy </li></ul></ul><ul><ul><li>Result presentation </li></ul></ul><ul><li>Case 1 – Diagnosis & Screening </li></ul><ul><li>Case 2 – Prognosis & Etiology </li></ul><ul><li>Case 3 – Therapy </li></ul>
  52. 59. Summary <ul><li>Contents (original, EBM review, review) </li></ul><ul><li>How to search? </li></ul><ul><ul><li>Keywords OR thesaurus/MeSH </li></ul></ul><ul><ul><li>Search strategy </li></ul></ul><ul><ul><li>Search refinements </li></ul></ul><ul><li>Results of search? </li></ul><ul><ul><li>Numbers of results </li></ul></ul><ul><ul><li>The order of results </li></ul></ul>
  53. 60. MD Consult <ul><li>Smarter, Easier & Better </li></ul><ul><li>One of the Best for background questions </li></ul><ul><li>Foreground questions </li></ul><ul><ul><li>High quality topics review in Clinics & Textbooks (may not be EBM style) </li></ul></ul><ul><ul><li>EBM-style review </li></ul></ul>
  54. 61. Suggestions for MD Consult <ul><li>Duplicated results in Journals & Clinics </li></ul><ul><li>Textbooks with publication year </li></ul><ul><ul><li>Textbook search result (order by ?) </li></ul></ul><ul><li>Increase topics with recommended result </li></ul><ul><li>Increase amount & sources of EBM-style reviews or guidelines </li></ul><ul><li>Patient education 中文版 , last update date </li></ul>
  55. 62. Easier Better Smarter

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