临床问题OVIDMEDLINE文献检索主要步骤.ppt

OVID MEDLINEOVIDMEDLINEOVIDMEDLINEv收錄收錄年代：年代：1946Currentv收錄主題範圍收錄主題範圍v收錄收錄內容：文獻之書目資料內容：文獻之書目資料、摘要摘要基礎醫學臨床醫學生物科學解剖學醫務管理學化學與藥物心理學社會醫學生物農業與營養醫材設備醫事技術醫事資訊MeSHMeSH醫學標題醫學標題醫學標題醫學標題TitleFRAX or fiction:determining optimal screening strategies for treatment of osteoporosis in residents in long-term care facilities.主標題：主標題：OsteoporosisDiphosphonatesCross-SectionalStudies副標題：副標題：OsteoporosisDiagnosisDrugtherapyEpidemiology文獻的重點為討論osteoporosis的流行病學研究，但文中有討論到治療及藥物治療而且是以Diphosphonates為主要治療用藥什麼是什麼是什麼是什麼是MeSHMeSH？運動、遊戲、娛樂圈、音樂運動、遊戲、娛樂圈、音樂.什麼都有什麼都有NLM在分析生物醫學方面之期刊文獻、圖書、視聽資料、電子資源等資源的主題時，為了將同一概念用固定的詞彙表達，於是建立一套醫學標題詞（MeSH），以達到控制詞彙的目的。索引專家們更在眾多標題詞中建立主題關係連結，可利用樹狀結構圖呈現可利用樹狀結構圖呈現出詞彙間語義或從屬上的關係。以固定的詞彙表達以固定的詞彙表達以固定的詞彙表達以固定的詞彙表達1.彙整同義詞至同一標題詞彙整同義詞至同一標題詞(MeSH)標題詞(MeSH)彙整的同義詞2.彙整彙整相同主題的文章相同主題的文章至同一標題詞至同一標題詞(MeSH)標題詞(MeSH)樹狀結構樹狀結構樹狀結構樹狀結構The“6S”levelsoforganizationofThe“6S”levelsoforganizationofevidencefromhealthcareresearchevidencefromhealthcareresearchComputerizeddecisionsupportEvidence-basedclinicalpracticeguidelinesEvidencebasedtextbookACPJournalClub、DARESystematicreviewsOriginaljournalarticlesComputerSummariesSynopsesofSynthesesSynthesesStudiesSynopsesofstudiesACPJournalClubbyRBrainHaynes,2009byRBrainHaynes,2009 二次研究證據二次研究證據(已經整理的文獻)1.System系統系統2.Summaries(1)Best Practice-Clinical Evidence(2)UpToDate(3)ACP Pier&ACP Medicine(4)DynaMed(5)Medscape-eMedicine(free)3.SynopsesofSyntheses (1)ACP Journal Club(2)Evidence-based Medicine(3)Evidence-based Nursing(4)Database of Abstracts of Reviewsof Effects(DARE)4.Syntheses統整（統整（Systematic reviews）(1)The Cochrane Library-CDSR&Other Reviews(中文版摘要 free)(2)ACPJC PLUS(3)Medline之systematic review 5.Synopses of Syntheses 原始研究證據原始研究證據(未經整理的文獻)6.Studies（Original journals articles）(1)The Cochrane Library-Clinical trials(2)PubMed-Clinical Queries之Clinical study search(free)(3)Medline(善用 more limit之功能)搜尋流程(自二次研究證據找起)臨床決策模型臨床決策模型臨床決策模型臨床決策模型JAmMedInformAssoc.1997Jul-Aug;4(4):266-78.ElsonRB,FaughnanJG,ConnellyDP實證醫學三大要素實證醫學三大要素實證醫學三大要素實證醫學三大要素EvidenceExperienceExpectationEBMMayusingAspirinpreventcolorectalcancer？臨床問題臨床問題臨床問題臨床問題OVIDMEDLINEOVIDMEDLINE文獻檢索主要步驟文獻檢索主要步驟文獻檢索主要步驟文獻檢索主要步驟檢索自然語言、關鍵字MeSH條件限制ClinicalQueriesPublicationType輸出書目資料管理全文、內容檢檢索索原始關鍵字原始關鍵字Primary Term 或或MeSH Term 同義字同義字1同義字同義字2P(oror)andI(aspirinoracetylsalicylicacidor)andC(oror)andO(ColorectalCancerorColorectalNeoplasmor)BASICSearshBASICSearshAdvancedSearch(MeSH)AdvancedSearch(MeSH)選擇主標題選擇主標題選擇副標題選擇副標題(找尋以找尋以prevention為主要研究方向的文獻為主要研究方向的文獻)條條件件限限制制ClinicalQueries(ClinicalQueries(找回找回找回找回reviewsreviews的文獻的文獻的文獻的文獻)以語彙控制為工具針對臨床行為做分類，senstivity為最嚴格、best balance次之，specificity為較鬆散的條件Sample年齡期刊收錄主題出版語系文獻研究方法Publicationtypes&subjectsubsetsPublicationtypes&subjectsubsets(systematicrevews(systematicrevews、mata-analysismata-analysis、RCTs)RCTs)Meta analysis 4 篇篇Systematic Review 14 篇篇RCTs 35 篇篇輸出全文輸出全文輸出輸出勾選文獻的書目資料實施實證醫學五大步驟實施實證醫學五大步驟實施實證醫學五大步驟實施實證醫學五大步驟整理出一個可以回答的問題asking an answerable question尋找文獻證據tracking down the best evidence嚴格評讀文獻critical appraisal應用於病人身上integrating the appraisal with clinical expertise and patients preference對過程進行稽核auditing performance in step 1-4步驟一步驟一整理出一個可以回答的問題整理出一個可以回答的問題臨床問題從哪裡來？臨床問題從哪裡來？臨床問題從哪裡來？臨床問題從哪裡來？臨床發現(clinicalfindings)病因(etiology)疾病的臨床表徵(clinicalmenifestationsofdiseases)鑑別診斷與診斷檢查(DDx&diagnostictest)治療(therapy)預後(prognosis)預防措施(prevention)（生病）的經驗與意義(experience&meaning)自我學習發展的過程(self-improvement)臨床臨床臨床臨床問題的種類問題的種類問題的種類問題的種類Therapy/Prevention：治療/預防的問題研究治療或預防方法的有效性例如：服用“阿斯匹林”是否可以預防中風？Diagnosis：診斷問題研究檢查方法或臨床表徵對疾病診斷的有效性例如：McBurneys sign 診斷急性盲腸炎的敏感度及特異度為何？Harm/Etiology：危害/病因問題研究暴露的危害或疾病的原因例如：停經婦女使用荷爾蒙治療是否會增加乳癌的機會？Prognosis：預後建立疾病預後的預測模式例如：利用Ransons criteria 預測急性胰臟炎死亡率為何？例如:In healthy women who have recently had a miscarriage(流產),what is the usual grieving(悲傷)process and are any factors associated with longer than normal grieving?步驟二步驟二尋找文獻證據尋找文獻證據LevelTherapy/Prevention,Aetiology/HarmPrognosisDiagnosisDifferentialdiagnosis/symptomprevalencestudyEconomicanddecisionanalyses1aSR(withhomogeneity*)ofRCTsSR(withhomogeneity*)ofinceptioncohortstudies;CDRvalidatedindifferentpopulationsSR(withhomogeneity*)ofLevel1diagnosticstudies;CDRwith1bstudiesfromdifferentclinicalcentresSR(withhomogeneity*)ofprospectivecohortstudiesSR(withhomogeneity*)ofLevel1economicstudies1bIndividualRCT(withnarrowConfidenceInterval)Individualinceptioncohortstudywith80%follow-up;CDRvalidatedinasinglepopulationValidating*cohortstudywithgoodreferencestandards;orCDRtestedwithinoneclinicalcentreProspectivecohortstudywithgoodfollow-up*Analysisbasedonclinicallysensiblecostsoralternatives;systematicreview(s)oftheevidence;andincludingmulti-waysensitivityanalyses1cAllornoneAllornonecase-seriesAbsoluteSpPinsandSnNoutsAllornonecase-seriesAbsolutebetter-valueorworse-valueanalyses2aSR(withhomogeneity*)ofcohortstudiesSR(withhomogeneity*)ofeitherretrospectivecohortstudiesoruntreatedcontrolgroupsinRCTsSR(withhomogeneity*)ofLevel2diagnosticstudiesSR(withhomogeneity*)of2bandbetterstudiesSR(withhomogeneity*)ofLevel2economicstudies2bIndividualcohortstudy(includinglowqualityRCT;e.g.,80%follow-up)Retrospectivecohortstudyorfollow-upofuntreatedcontrolpatientsinanRCT;DerivationofCDRorvalidatedonsplit-sampleonlyExploratory*cohortstudywithgoodreferencestandards;CDRafterderivation,orvalidatedonlyonsplit-sampleordatabasesRetrospectivecohortstudy,orpoorfollow-upAnalysisbasedonclinicallysensiblecostsoralternatives;limitedreview(s)oftheevidence,orsinglestudies;andincludingmulti-waysensitivityanalyses2cOutcomesResearch;EcologicalstudiesOutcomesResearchEcologicalstudiesAuditoroutcomesresearch3aSR(withhomogeneity*)ofcase-controlstudiesSR(withhomogeneity*)of3bandbetterstudiesSR(withhomogeneity*)of3bandbetterstudiesSR(withhomogeneity*)of3bandbetterstudies3bIndividualCase-ControlStudyNon-consecutivestudy;orwithoutconsistentlyappliedreferencestandardsNon-consecutivecohortstudy,orverylimitedpopulationAnalysisbasedonlimitedalternativesorcosts,poorqualityestimatesofdata,butincludingsensitivityanalysesincorporatingclinicallysensiblevariations.4Case-series(andpoorqualitycohortandcase-controlstudies)Case-series(andpoorqualityprognosticcohortstudies*)Case-controlstudy,poorornon-independentreferencestandardCase-seriesorsupersededreferencestandardsAnalysiswithnosensitivityanalysis5Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchorfirstprinciplesExpertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchorfirstprinciplesExpertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchorfirstprinciplesExpertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchorfirstprinciplesExpertopinionwithoutexplicitcriticalappraisal,orbasedoneconomictheoryorfirstprinciplesOxfordCentreforEvidence-basedMedicineLevelsofEvidence(May2001)OxfordCentreforEvidence-basedMedicineLevelsofEvidence(May2001)http:/ June 2010New研究設計研究設計研究設計研究設計分類分類分類分類(Ataxonomyofclinicalresearch)(Ataxonomyofclinicalresearch)bybyDavid A Grimes,Kenneth F David A Grimes,Kenneth F Schulz,2002Schulz,2002DidinvestigatorAssignexposures?ObservationalstudyExperimentalstudyComparisongroup?Randomallocation?RandomizedControlledtrialNon-RandomizedControlledtrialAnalyticalstudyDescriptivestudyDirection？CohortstudyCase-controlstudyCross-sectionalstudyYesYesYesNoNoNoExposureOutcomeExposureOutcomeExposureandOutcomeatsametimeGeneratingevidencefromresearchSynthesisingtheevidenceCreatingevidencebasedclinicalpoliciesApplyingthepoliciesBrian Haynes,Andrew Haines.Education and debate:Getting research findings into practice:Barriers and bridges to evidence based clinical practice.BMJ 1998;317:273-276.Steps to the solution as proposed 文獻結果文獻結果文獻結果文獻結果Meta analysis1.Aspirinforthechemopreventionofcolorectaladenomas:meta-analysisoftherandomizedtrials.SystematicReviewSystematicReview1.Aspirinforthepreventionofcolorectalcancer.ReviewRandomizedControlledTrialRandomizedControlledTrial1.Preventionbydailysolubleaspirinofcolorectaladenomarecurrence:4-yearresultsoftheAPACCrandomisedtrial.Thank You!