OVID MEDLINE

EBM (Evidence-based Medicine) 以證據為基礎的醫學 實證醫學乃是從龐大的醫學資料庫中搜尋相關文獻， 並以流行病學及統計學方法過濾出值得信賴的文獻， 再經過嚴格評讀及綜合分析後，將所獲取之最佳研 究證據 (evidence) 、臨床經驗 (experience) 及患者期望 (expectation) 相互整合，配合診療情境後制定出一套 最佳的臨床醫療決策，並可用來協助醫護人員進行 終身學習。 Not only a skill but also an attitude change for everyone in hospitals

臨床決策模型 J Am Med Inform Assoc. 1997 Jul-Aug;4(4):266-78. Elson RB, Faughnan JG, Connelly DP

實證醫學三大要素 Evidence EBM Experience Expectation

臨床問題從哪裡來？ 臨床發現 ( clinical findings ) 病因 ( etiology ) 疾病的臨床表徵( clinical menifestations of diseases ) 鑑別診斷與診斷檢查 ( DDx & diagnostic test ) 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：McBurney’s 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Ranson’s 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?

Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001) Therapy/Prevention, Aetiology/Harm Prognosis Diagnosis Differential diagnosis/symptom prevalence study Economic and decision analyses 1a SR (with homogeneity*) of RCTs SR (with homogeneity*) of inception cohort studies; CDR† validated in different populations SR (with homogeneity*) of Level 1 diagnostic studies; CDR† with 1b studies from different clinical centres SR (with homogeneity*) of prospective cohort studies SR (with homogeneity*) of Level 1 economic studies 1b Individual RCT (with narrow Confidence Interval‡) Individual inception cohort study with > 80% follow-up; CDR† validated in a single population Validating** cohort study with good††† reference standards; or CDR† tested within one clinical centre Prospective cohort study with good follow-up**** Analysis based on clinically sensible costs or alternatives; systematic review(s) of the evidence; and including multi-way sensitivity analyses 1c All or none§ All or none case-series Absolute SpPins and SnNouts†† Absolute better-value or worse-value analyses †††† 2a SR (with homogeneity*) of cohort studies SR (with homogeneity*) of either retrospective cohort studies or untreated control groups in RCTs SR (with homogeneity*) of Level >2 diagnostic studies SR (with homogeneity*) of 2b and better studies SR (with homogeneity*) of Level >2 economic studies 2b Individual cohort study (including low quality RCT; e.g., <80% follow-up) Retrospective cohort study or follow-up of untreated control patients in an RCT; Derivation of CDR† or validated on split-sample§§§ only Exploratory** cohort study with good†††reference standards; CDR† after derivation, or validated only on split-sample§§§ or databases Retrospective cohort study, or poor follow-up Analysis based on clinically sensible costs or alternatives; limited review(s) of the evidence, or single studies; and including multi-way sensitivity analyses 2c "Outcomes" Research; Ecological studies "Outcomes" Research   Ecological studies Audit or outcomes research 3a SR (with homogeneity*) of case-control studies SR (with homogeneity*) of 3b and better studies 3b Individual Case-Control Study Non-consecutive study; or without consistently applied reference standards Non-consecutive cohort study, or very limited population Analysis based on limited alternatives or costs, poor quality estimates of data, but including sensitivity analyses incorporating clinically sensible variations. 4 Case-series (and poor quality cohort and case-control studies§§) Case-series (and poor quality prognostic cohort studies***) Case-control study, poor or non-independent reference standard Case-series or superseded reference standards Analysis with no sensitivity analysis 5 Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles" Expert opinion without explicit critical appraisal, or based on economic theory or "first principles" All or none study(本來的疾病個案都會死亡，只要有新治療能讓一個人存活，就代表是有效的治療。)

New http://www.cebm.net/index.aspx?o=5653 10 June 2010

研究設計分類 ( A taxonomy of clinical research) by David A Grimes, Kenneth F Schulz,2002 Did investigator Assign exposures? Observational study Experimental study Comparison group? Random allocation? Randomized Controlled trial Non-Randomized Analytical study Descriptive Direction？ Cohort Case-control Cross- sectional Yes No Exposure  Outcome Exposure  Outcome Exposure and Outcome at same time

The “6S” levels of organization of evidence from health care research Computerized decision support Evidence-based clinical practice guidelines Evidence based textbook ACP Journal Club、DARE Systematic reviews Original journal articles by R Brain Haynes, 2009 Computer Summaries Synopses of Syntheses Syntheses ACP Journal Club Synopses of studies Studies

搜尋流程 (自二次研究證據找起) 二次研究證據 (已經整理的文獻) 1. System系統 2. Summaries – for Background questions (1) Evidence-based CPG (free) (2) Best Practice-Clinical Evidence (3) UpToDate (4) ACP Pier & ACP Medicine (5) FirstConsult (6) DynaMed (7) Medscape-eMedicine (free) 3. Synopses精要（ Article reviews ） - for Background questions (1) ACP Journal Club (2) Evidence-based Medicine (3) Evidence-based Nursing 4. Syntheses統整（ Systematic reviews ） - for Foreground question (1) The Cochrane Library - CDSR & Other Reviews (中文版摘要 free) (2) PubMed-Clinical Queries之 systematic review (free) (3) Medline之systematic review 原始研究證據 (未經整理的文獻) 5. Studies（ Original journals articles ）- for Foreground question (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)

OVID MEDLINE 收錄年代：1946~Current 收錄主題範圍 收錄內容：文獻之書目資料、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

MeSH 醫學標題 Title FRAX or fiction: determining optimal screening strategies for treatment of osteoporosis in residents in long-term care facilities. 主標題：Osteoporosis Diphosphonates Cross-Sectional Studies 副標題： Diagnosis Osteoporosis Drug therapy Epidemiology 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MeSH？ 運動、遊戲、娛樂圈、音樂.....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出詞彙間語義或從屬上的關係。

以固定的詞彙表達 彙整同義詞至同一標題詞(MeSH) 標題詞(MeSH) 彙整的同義詞

彙整相同主題的文章至同一標題詞(MeSH)

樹狀結構

搜尋流程 (自二次研究證據找起) 二次研究證據 (已經整理的文獻) 1. System系統 2. Summaries (1) Best Practice-Clinical Evidence (2) UpToDate (3) ACP Pier & ACP Medicine (4) DynaMed (5) Medscape-eMedicine (free) 3. Synopses of Syntheses (1) ACP Journal Club (2) Evidence-based Medicine (3) Evidence-based Nursing (4) Database of Abstracts of Reviewsof Effects (DARE) 4. Syntheses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 (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)

臨床問題 Which therapy have more benefit for Atopic Dermatitis either Tacrolimus or Corticosteroids.

原始關鍵字Primary Term 或MeSH Term 同義字1 同義字2 P ( Atopic Dermatitis with children or ) and I Tacrolimus C Corticosteroids O quality of life

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