第三十屆醫學圖書館工作人員研討會 2008-09-19 13:30-14:30 王雅怡 實證醫學資料庫檢索技巧 第三十屆醫學圖書館工作人員研討會 2008-09-19 13:30-14:30 王雅怡

大綱 實證醫學概念 EBM 5S Model EBM Pyramid 實證問題類型與檢索策略 實證醫學資源檢索技巧

“Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” - Sackett, et al 2001 七季第二集15:45 Start with a question http://tw.youtube.com/watch?v=b22g8JtoJms 實證醫學概念

實證醫學五步驟 形成一個可以回答的臨床問題 搜尋最佳證據 嚴格評讀證據之效度與重要性 將臨床專業與病人價值觀相結合 評估執行效果及效用 PICO 搜尋資料 實證醫學五大步驟 實證醫學教育包括四個基本步驟：提問、搜尋、評讀及應用證據。以下是一個簡單的指引。 步驟一： 形成一個可以回答的臨床問題 怎麼樣才算是對病人有幫助的問題？問題的重點為何？試著將您的問題分成下列四個部分(PICO)： 病人或問題 介入或指標－某種治療、檢查、危險因子等 比較－該治療和什麼相比？ 結果－您想要達成或避免什麼？ 步驟二： 搜尋最佳證據 利用問題的PICO結構（如上述）設定搜尋策略。回想問題中各部份的每一個詞彙及其同義詞。一次就單一PICO元素進行搜尋。 以上這些問題的答案，通常可以在文章中的方法學部分和結果的第一、二段中找到。這樣的評讀，一開始可能令您覺得困難重重，但是，累積了一些經驗之後，您只要幾分鐘就能完成。 步驟三： 嚴格評讀證據之(a) 效度 與 (b) 重要性 (a) 效度 各種型式的問題都包含以下三個共同項目： 1. 研究族群是否具有代表性？（隨機選擇/連貫性/起始點病人群），或者如果是比較性的，組別間是否可以比較？（隨機分派/調整） 2. 是否有足夠的確認和追蹤？ 3. 結果的估計值是否公正？恰當？（使用盲法或客觀的估計） (b) 重要性－效益大小 請看結果段中所描述的主要結果。效果有多大？多重要？ 統計意義要看信賴區間及p值；臨床意義則要看效果的估計值： 效果的相對估計值：相對危險、相對危險性降低度、勝算比代表生物學上的影響。 效果的絕對估計值：絕對危險性降低度、益一需治數則代表在臨床上對病人的影響。 步驟四： 將臨床專業與病人價值觀相結合 您的病人是否與研究中的病人差別很大，以至於無法適用該研究結果？ 您期望您的病人從研究結果中獲得多大的好處？ 還有哪些替代方案？ 研究結果適用於您的病人嗎？ 病人的想法為何？ 研究效果需要因應個別病人做調整。 步驟五： 評估執行效果及效用－勤做紀錄，改善過程 最後一個步驟來看看：在實證醫學的執行過程中，您的表現如何？ 您可能要問自己下列幾個問題： 您正在記錄您的問題嗎？ 您是否正在廣大的資源中尋找有用的外部證據？ 您搜尋及評讀證據的速度有多快？ 您有能力將這些證據應用在適當的病人身上嗎？ 您是否依循這些新證據來改變您的診療習慣？ 由台北醫學大學．市立萬芳醫院實證醫學中心經授權作中文編譯，英國The Centre for Evidence-Based Medicine及The National Library for Health, NHS所出版由Carl Heneghan及Paul Glasziou撰寫之Quesions Log: A tool for ' just in time' learning手冊。

形成一個可回答的臨床問題 P Patient/Population or Problem 病人或族群的年齡層、體質、疾病史、過去史 Ex: A 50 year-old woman with a family history of breast cancer I Intervention or Indicator 治療、診斷、預後、成本效益分析等研究的主題 Ex: Hormone replacement therapy C Comparator 有無其他方式或選擇? Ex: Placebo O Outcome 效果是甚麼?或是預計的結果？ Ex: Prevention of Alzheimer’s disease 圖書資訊學檢索 H的思考：who how when what why where 實證醫學思考：PICO Patient: Patient Basic Background Intervention or Indicator: 預後-預測以後 Comparator: 比較 Outcome: 預期效益 PICO的好處：(1)聚焦問題，容易找到關鍵字。(2)分辨臨床問題的型態，如Thearapy治療、Harm傷害、Diagnosis診斷、Prognosis預後與Etiology病因等類別。(3)協助瞭解何者是最好且最適合之研究設計，據此而產生之研究結果才是最佳證據等級的文獻。 衛生政策數位學院 http://ehealthpolicy.nhri.org.tw/lecture.htm ，實證醫學資料庫推廣專案種子師資培訓營

搜集最佳證據 使用資訊技術協助搜尋，配合搜尋輔助工具與 MeSH 語法 PICO 問題轉譯成適當關鍵字，組織檢索語句 選擇合適之資訊資源檢索 適當使用布林邏輯 AND, OR, .....，縮小搜尋結果至約10至30篇 使用資訊技術協助搜尋，配合搜尋輔助工具與 MeSH 語法 MeSH 醫學專業詞彙 eg. PubMed Clinical Query  eg. [dp] = date of publish; [ptyp] = publication type 國泰醫院實證醫學中心 http://ebm.cgh.org.tw/ebm-handon-6quar，六刻鐘EBM套餐

嚴格評讀證據的效度與重要性 考量證據之信度(Reliability)、效度(Validity)、重要性(Importance)、實際運用之可能(Applicability) 參考Oxford Center of EBM 的分級表，強調不同主題的研究有不一樣的分級標準 Answer: 資訊與問題的關聯度? Author: 作者之權威性? Patient: 取樣的代表性? Comparison / Intervention: 是否有清楚的描述(Ascertain)? 是否實際可行? Outcome: 是否有統計學或臨床上的意義？ Time: 是否清楚描述研究取樣、操作、結果測量的時間點，追蹤時間是否夠長? 衛生政策數位學院 http://ehealthpolicy.nhri.org.tw/lecture.htm ，實證醫學資料庫推廣專案種子師資培訓營 Centre For Evidence-Based Medicine Levels of Evidence http://www.cebm.net/?o=1023

Critical Appraisal WorkSheet National Health Service CASP Tools Centre For Evidence-Based Medicine University Health Network 實證醫學操作概要 李智雄主任 診斷工具的研究，結果常以兩種方式呈現： 檢驗或檢查的準確度 Sensitivity (敏感度) Sn Specificity (特異度) Sp 檢驗或檢查在某一群體的預測值 Positive predictive value (陽性預測值 ) PPV Negative predictive value (陰性預測值 ) NPV LR+ = Sensitivity / (1-specificity) 0.96 / (1 – 0.8) = 4.8 LR- = (1-sensitivity) / specificity (1 – 0.96) / 0.8 = 0.05 Pre-test odds = prevalence / (1 - prevalence) 0.25 / 0.75 = 0.3333 Post-test odds = pre-test odds X likelihood ratio 0.3333 X 4.8 = 1.5998 Post-test probability = post-test odds/(post-test odds + 1) 1.5998 / (1.5998 + 1) = 0.6154 將臨床專業與病人價值觀相結合 您的病人是否與研究中的病人差別很大，以至於無法適用該研究結果？ 您期望您的病人從研究結果中獲得多大的好處？ 還有哪些替代方案？ 研究結果適用於您的病人嗎？ 病人的想法為何？ 研究效果需要因應個別病人做調整。 http://www.phru.nhs.uk/pages/phd/resources.htm http://www.cebm.utoronto.ca/teach/materials/caworksheets.htm 將臨床專業與病人價值觀相結合

評估執行效果及效用 臨床日誌 成功大學醫院之臨床日誌

Haynes, R. (2006, November). 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-A9. Retrieved August 11, 2008, from Academic Search Premier database. EBM 5S MODEL

EBM 5S Model 醫療決策系統 連結個別病患特徵資訊 Computerized decision support systems that link individual patient characteristics to pertinent evidence System Summary Synopses Syntheses Original Studies 對一項疾病摘要 基礎至完整之實證資訊 BMJ Clinical Evidence ACP PIER UpToDate DynaMed 對於原始文章或評論之 簡單描述/概要 ACP Journal Club Evidence-Based Medicine Evidence-Based Nursing 綜合評論/統合文獻 BMJUpdates+ The Cochrane Library PubMed Clinical Queries System: 醫療決策系統連結個別病患特徵資訊Computerized decision support systems that link individual patient characteristics to pertinent evidence Summary總結一覽: 對一項疾病摘要基礎至完整的實證資訊Summaries integrate best available evidence from the lower layers to provide a full range of evidence concerning management options for a given health problem(Evidence Based Textbooks) Synopses概要: 對於原始文章評論之簡單描述Very brief descriptions of original articles and reviews(Evidence Based Journal Abstract) Syntheses綜合體: 綜合評論Systematic reviews systematic review定義：針對特定的疾病或健康照顧問題的治療方法評斷其療效。作者盡可能從許多相關科學研究做出這些定義、評價和綜合實證。他們簡述關於療效，並針對特定主題提供經過實證的獨特收藏。讓其他人可以很容易的檢閱這些針對各種治療方式之原始研究。Systematic reviews和其它型式的review不同的地方為Systematic reviews 它堅持用精確的設計來使它們的內容更廣泛，以降低誤差的機率，並增加它的可信度 Original Studies原始文獻 金字塔愈上層資源越少 System知識庫在國外通常會和醫令系統(HIS)一起作..會有開錯藥有警告旯等等的~ 引進 但是會牽扯到醫令系統全面更新~ 很複雜咧~ 所以目前的作法是我們再clineguide裡的漢醫令結合的畫面那樣作串聯 後端是知識庫~ 但是會結合醫令系統中的邏輯判斷.. 譬如高血壓病人，可能有些藥是不能使用，如果醫護人員開了要，系統會警示，然後顯示香甘說明~ 類似這樣的~ 目前所知沒有真的很成熟的產品 醫令系統經由電腦來處理門診醫師及護理人員在診間所發生的一切醫療資訊，包括患者主訴、醫師之臨床客觀發現、檢驗、檢查單的開立、預約處理等。 與醫院其他單位，如檢驗室、藥局等，做醫囑資訊之互相傳送。經由電腦作業取代傳統的人力作業，可降低錯誤率的發生 當不確定選擇何種資源檢索，或資源未涵蓋實證問題時，另可使用Federated Search Engines進行跨資源檢索，但需留意檢索資訊之品質。 TRIP (http://www.tripdatabase.com) and SUMsearch (http://sumsearch.uthscsa.edu/) If you are not familiar with which evidence-based resource is best for a particular clinical problem — or you know that the resources you usually use don‘t cover the problem at hand — then “federated search engines,” such as TRIP (http://www.tripdatabase.com) and SUMsearch (http://sumsearch.uthscsa.edu/), provide means to search many resources, with the retrieval being organized according to the source of evidence. But if you use such services, you will need to keep your critical appraisal filters on alert: The quality of the retrieval depends on the source, and many sources do not provide critical appraisal of evidence. 原始文獻 BMJUpdates+ PubMed Clinical Queries 當不確定選擇何種資源檢索，或資源未涵蓋實證問題時，另可使用Federated Search Engines進行跨資源檢索，但需留意檢索資訊之品質。 TRIP (http://www.tripdatabase.com) and SUMsearch (http://sumsearch.uthscsa.edu/)

實證醫學文獻金字塔與檢索資源 EBM PYRAMID

EBM文獻類別 systematic review系統性回顧：系統性回顧，為針對一個清楚的問題，使用有系統且清楚的方法去確認、篩選及評判相關原始研究文獻，選出高品質的文獻，針對其結果加以整合分析討論。針對入選的原始文獻，若測量結果方式相似，則可以進一步用統計的方法加以統合分析(meta-analysis) 。若測量結果方式不相似，則無法進行統合分析。(資料來源:彰基醫圖電子報第3期) Meta-Analysis統合分析：統合分析，使用統計方法將系統性回顧文獻內所包含的各篇原始研究結果，加以統合分析。有時是系統性回顧文獻合併統合分析的簡稱。(資料來源:彰基醫圖電子報第3期) Cohort study世代研究：世代研究，是一種觀察性研究方法(observational study)，一群界定清楚的人 (the cohort) 被追蹤一段時間。檢驗結果( outcome) 在不同次群組之間是否有差異，例如有（或沒有）暴露在某種介入之次群組，觀察其結果發生率。世代研究大多是前瞻性的，但也有少數是回溯性的（必須相關記錄非常清楚）。(資料來源:彰基醫圖電子報第3期) Case control study病例對照研究：病例對照研究係針對研究者有興趣的特定疾病或試驗結果，比較族群中有該疾病或結果(試驗組)與無該疾病或結果(對照組)的二群人，找出疾病或結果與其先前暴露的危險因子之關連性。對少數或罕見且既往暴露可被準確量測的疾病，病例對照研究有助於相關性的確定，且一般上多都採回溯性研究方式進行，但也不全然只能採回溯性研究方式進行。(資料來源Green S, Higgins J, editors. Glossary. Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 [updated May 2005]. http://www.cochrane.dk/cochrane/handbook/handbook.htm [(accessed 30/08/2006)]. Case-series: Report of a number of cases of disease. (Harm/Etiology) RCTs, Case Cohorts, Control Studies Randomized controlled trial(有隨機有對照組的實驗): An experimental comparison study in which participants are allocated via a randomization mechanism to either an intervention/treatment group or a control /placebo group, then followed over time and assessed for the outcomes of interest.  Participants have an equal chance of being allocated to either group. (Therapy) Double Blind A double blind study is one in which neither the patients nor the health care personnel involved in treatment know whether a particular patient is receiving the treatment being studied or is part of the control group.  Clinical Research Critiques：Reviews of patient care relevant studies. Clinical practice guidelines (CPG) 臨床診療指引：臨床診療指引，定義為“以系統性方法發展的醫療建議或陳述，用以協助醫師與病人決定在特定的臨床情況下適當之醫療照護”。美國IOM對好的臨床指引之規範包括指引內容清楚、有效、可信、具臨床應用性及彈性、提供證據強度、結果可預期、多專業參與指引發展、定期檢討及適當的文件形式等。（Institute of Medicine (1990). Clinical Practice Guidelines: Directions for a New Program, M.J. Field and K.N Lohr (eds.) Washington, DC: National Academy Press） Based on material from SUNY Downstate Medical Center/Medical Research Library of Brooklyn Pyramid modified from "Navigating the Maze", University of Virginia, Health Sciences Library http://library.downstate.edu/EBM2/2100.htm http://healthlinks.washington.edu/ebp/ebptools.html

EBM相關名詞解釋 國家衛生研究院 實證臨床指引平台 Evidence Based Medicine Toolkit Clinical Epidemiology Glossary http://ebpg.nhri.org.tw/Module/Content.aspx?catalog=94 http://www.ebm.med.ualberta.ca/Glossary.html

Evidence-Based Practice Tools Summary Cochrane Library Cochrane Database of Systematic Reviews (Cochrane Reviews) Database of Abstracts of Reviews of Effects (Other Reviews - DARE)   PubMed MEDLINE - Systematic Reviews   BMJ Clinical Evidence DynaMed USPSTF Guidelines | AHRQ Evidence Reports | FPIN Clinical Inquiries included in Journal of Family Practice and American Family Physician Indexed in PrimeAnswers      PubMed Clinical Queries Cochrane Library Cochrane Central Register of Controlled Trials (Clinical Trials)   ACP Journal Club POEMS (Patient Oriented Evidence that Matters) Bandolier | BestBETs   Natural Medicines Comprehensive Database   PubMed National Guideline Clearinghouse  PrimeAnswers | Care Provider Toolkit   University of Washington Resources http://healthlinks.washington.edu/ebp/ebptools.html http://healthlinks.washington.edu/ebp/

實證醫學資料庫檢索

欲提供實證以答覆問題時，醫師最常見的6個障礙 發掘實證醫學資料之前所面對的障礙 欲提供實證以答覆問題時，醫師最常見的6個障礙 找尋資訊時所需耗費的時間 難以重新描述，以符合最初的原始問題 難以選擇搜尋條件與執行搜尋策略 選擇錯誤的方向與資源，回答問題 當擁有所有的相關實證後，答案卻不明確 許多未經過充份系統性整理的實證資訊碎片 Ely, J. W., Osheroff, J. A., Ebell, M. H., Chambliss, M. L., Vinson, D. C., Stevermer, J. J., et al. (2002). Obstacles to answering doctors‘ questions about patient care with evidence: qualitative study. BMJ, 324(7339), 710.

資訊檢索協助 (圖書館員之角色) 使用適當的關鍵字查詢 訂定關鍵字查詢先後 利用資料庫檢索工具精確檢索結果 適當使用檢索工具和運用檢索技巧查詢 利用Map Term to Subject Heading比對到MeSH專業主題 利用布林邏輯合併檢索結果 限制性條件 相關詞彙，臨床觀念改變，需要不同的查詢用詞 不同實證資源的查找 適當引用臨床指引 (Clinical Practice Guideline, CPG)或教科書資訊 直接提供問題解答 可供間接參考，修正更深入思考模型，或釐清原先不清楚的關鍵字，把問題問更好  可特別說明「臨床指引」資料庫的查詢結果，交代哪些醫學會對怎樣的問題有共識 記錄檢索之詞彙、策略、檢索資源、檢索結果筆數、文獻年代、文獻特性

Cochrane Library  依據各個資料庫瀏覽  關鍵字檢索  MeSH檢索 Cochrane Reviews(CDSR)：疾病與健康照護問題系統性評論與治療效果結論全文。 Other Reviews(DARE)：診斷測試、公共衛生、藥理、外科、心理等系統性評論摘要與特殊療法效用。 Clinical Trials(CENTRAL)：臨床實驗計畫索引。 Methods Studies(CMR)：臨床實驗計畫摘要，蒐集各實驗方法資訊。 Technology Assessments(HTA)：全球健康管理技術(即醫療科技)評估計畫索引 Economic Evaluations(NHSEED)：治療方式比較、成本、效果等醫療經濟評估文獻摘要。 http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME

Cochrane Library —檢索詞彙修正參考 查詢MeSH標題 查詢索引典 瀏覽MeSH定義 瀏覽檢索結果 Qualifiers用Ctrl多選 選擇修飾語 選擇MeSH

Cochrane Library —閱讀檢索結果 依據資源項目瀏覽檢索結果 縮小檢索範圍 依據文獻類型瀏覽結果 (1)Reviews: 完整的結果和討論、資料分析和相關的圖表 (2)Protocols: Reviews的準備大綱，包括背景、原理說明和方法 (3)Comment: 完整的Review並含有評論及批評。使用者可以提出自己的評論，這些評論會被整合到編輯群的回答與回饋中 (4)New: 最新一季版本中所蒐錄的Protocol或Review (5)Updated: 表示最新一季的版本做過更新 (可查詢更新前的全文) (6)Withdrawn: 被撤消的Review或Protocol，撤消的理由會在該篇文章上詳細說明

PubMed  Choose Search Function Search by Clinical Study Category Find Systematic Reviews Filter Table列有如Therapy, broad or narrow定義 Search Subject with Category and Scope  Clinical Queries Search Search Subject for systematic review, meta-analyses http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml

PubMed—檢索詞彙修正參考 Search Keyword Search PubMed Send to Select MeSH  Search Box with AND/OR/NOT Select MeSH  MeSH Database Search other MeSH and repeat  Link PubMed Major Topic

PubMed—檢索詞彙修正參考 Browse Details Check Translations for Searched MeSH Display Citations Browse Article's related MeSH

PubMed—篩選資料 Limits加入限制性條件 出版時間 類別  文章 類型  欄位 檢索

PubMed—篩選資料 Register  Results Filter by Setting  Choose Filter Personal Account  Click Results Filter by Setting  Choose Filter Add Filter Function to Personal Environment

Vivisimo ClusterMed™ Organizes PubMed® Search Results  Alternate Clustering  View at PubMed  Show in Clusters  Your Search, Clustered  Expandable Abstracts  Search Within Search http://vivisimo.com/press/2004/clustermedlaunch-20040401 http://ClusterMed.Info

OVID Medline—檢索詞彙修正參考 Include Related Terms  Find Similar  Search Term link to MeSH Tree  Narrow Search  MeSH http://gateway.ovid.com/

OVID Medline—篩選資料 Map Term to Subject Heading EBM Reviews  alzheimer’s disease Map Term to Subject Heading EBM Reviews  Basic Limits 年齡層 期刊類別 Additional Limits 動物 發表語言 Additional Limits的出版類型 臨床決策 特定主題類別 實證文獻 建議使用來篩選Medline提供EBM資料 EBM Reviews實證醫學資料庫，包括七個子資料內容 Cochrane Database of Systematic Reviews (CDSR) Database of Abstracts of Reviews of Effects (DARE) Cochrane Central Register of Controlled Trials (CCRCT) Cochrane Methodology Register (CMR) Health Technology Assessment Database (HTA) NHS Economic Evaluation Database (Economic Evaluations) ACP Journal Club Advanced Limits 出版類型 研究範疇 臨床決策 文獻索引 實證文獻 特定主題類別

OVID Medline—篩選資料 以Head為例 Explode：延展查詢 不勾選 勾選 Focus：精準查詢 檢索意義 單純查詢有討論該標題的文獻 延展標題查詢，在查詢結果數量上相對最多 查詢目標 文獻有討論到 Head即可被查出 查詢所有討論Head以及所有子標題(包括Ear, Eye, Eyebrows, Eyelashes, Lip…)的文獻 顯示 Head/ Exp Head/ 標題精確查詢 查詢結果數量上相對較少 兼顧文獻廣度與深度 查詢所有主要討論Head的文獻資料 查詢所有主要討論Head以及所有子標題(包括Ear, Eye, Eyebrows, Eyelashes, Lip…)的文獻 *Head/ Exp *Head/ Explode/Focus Explode: 查詢所有討論標題與子階層標題之文獻 Focus: 查詢主要討論標題之文獻 勾選Explode&Focus: 查詢所有主要討論標題與子階層標題之文獻

OVID Medline—檢索詞彙修正參考 Search Tools Map Term：主題比對；等同於Advanced Ovid Search之Map Term to Subject Heading。 Tree：顯示以樹狀構造排列之主題表；標準控制詞彙以具階級架構的樹狀圖排列，使用者可以了解輸入之關鍵字或片語可對應的主題所在位置以及了解相關父階層或子階層的主題。 Permuted Index：替代索引；藉由輸入單一關鍵字顯示所有包含此關鍵字的主題、Related terms和Used-for terms等。 Scope Note：名詞解釋；提供該標準主題詞彙的參考資料。 Explode：延展主題查詢；延展搜尋結果，包含該主題以及子階層之主題。 Subheadings：指定MeSH的副標題查詢；查詢並顯示標準主題詞彙的副標題，副標題詞幫助者找尋描述某一標題詞特定觀點資料。 Floating Sub-Heading (FS)：指定特定副標題詞查詢 Exploded Sub-Heading (XS)：某些副標題詞實際上又可以被歸類成同一類主題，目前共有31類。 Map Term: 比對MeSH標題Map Term to Subject Heading Tree: 瀏覽MeSH Tree Permuted Index: 包含此關鍵字的主題 Scope Note: 名詞解釋 Explode: 延展主題，包含主題與子階層主題 Subheadings: 查詢特定詞彙之副標題 Ex: AIDS的副標題 切換為Search Fields Floating Sub-Heading: ae.fs表示查詢副標題有Adverse Effects之MeSH標題 Exploded Sub-Heading: ae.xs副標題有Adverse Effects、Poisoning和Toxicity之MeSH標題 Search Tools的 Map Term功能主要是詞彙去比對所屬之MeSH標題 Tree功能是顯示詞彙所屬知識數架構 Permuted Index功能是以某一詞彙為主，顯示MeSH標題中有包含到此一詞彙之所有MeSH標題清單 Subheading功能以某一MeSH標題詞彙檢索，顯示OVID共通性的Subheading來協助篩選特定觀點資料 Search Fields的功能 Floating Subheading是指查找特定的副標題，提供包含此特定副標題之文獻 Exploded Subheading是指在查找特定副標題時，若其他副標題與此特定副標題有詞彙概念上相通時，提供包含此特定副標題，以及其他概念相同之副標題之文獻 Search Fields的display index功能是顯示詞彙在OVID中索引典 Search功能是直接將下入的關鍵字依據比對方式進行檢索 但是哪個功能是檢索詞彙 可以顯示其專門的subheading? ae.fs表示查詢副標題有Adverse Effects之MeSH標題 ae.xs表示查詢副標題有Adverse Effects、Poisoning和Toxicity之MeSH標題 35 35

Ovid Medline EBM 文獻查詢順位 Systematic Review Cochrane System Review Health Technology Assessments ACP Journal club Meta-Analysis Consensus Development Reports Decision Analyses Guideline/Practice Guideline --------Clinical Queries-------- RCTs Double Blind studies (therapy, diagnosis) Controlled Clinical Trials Multicenter Studies Crossover Design Cohorts Studies (prognosis, etiology, prevention) Longitudinal Studies Follow-Up Studies Prospective Studies Case Control Studies Retrospective Studies Cross-Sectional Survey Review Case Series/Case Reports 建議在使用Medline查找EBM文獻時 從SR—RCT--…Case Reports

OVID Medline—篩選資料 執行主題之查詢 Advanced Ovid Search→Map Term to Subject Heading → Explode → SubHeadings：透過 MeSH及SubHeading篩選方式，提供精確查詢 使用 Limits/Additional Limits篩選 Limits → EBM Reviews/evidence based medicine reviews：包含Cochrane和ACP Jnl club收錄之文獻（與Ovid EBM結合） Additional Limits →Subject Subsets /Systematic reviews：在Medline中被歸類於實證之文獻 3 not 2(驗算)：表示Medline中除了Cochrane或ACP收錄之文獻之外，還有其它也被歸類於實證之文獻資料 Additional Limits→Publication Types /Guideline以及Practice Guideline (單純運用一種篩選機制） Additional Limits→ 同時選擇(1)Publication Types/randomized controlled trial +(2)Clinical Queries /Therapy (optimized)：同時以clinical queries與Publication Type設定找出臨床治療之RCT文獻 (同時運用兩種以上之篩選機制） 若無適當資料，使用Subject Heading Keyword或Map term可適時擴大查詢範圍 Additional Limits→Publication Type/Multicenter study：以出版類型查詢Multicenter study文獻 Search Field→勾選Subject Heading Word→ 輸入Multicenter：以Multicenter為關鍵字查詢MeSH 8 and 1：表示MeSH標題中有Multicenter之文獻資料，與7比較，結果筆數較多 7 or 9：與9之結果筆數相同，表示9之結果包含7之結果 Search Tools→Map Term：Multicenter，可查出有兩個MeSH標題 11 and 1：驗算結果與9相同 1.Subject Search: 阿茲海默症之治療Explode with subheading治療 alzheimer disease->Map Term to Subject Heading->Explode所有討論到主題含子標題文獻->subheading: Diet Therapy, Nursing, Therapy, Rehabilitation, Drug Therapy, Prevention & Control, Surgery. 2. Limits EBM Reviews文獻 Limits→ EBM Reviews/evidence based medicine reviews：包含Cochrane和ACP Jnl club收錄之文獻 (需訂購EBM) 3. Limits Systematic Reviews文獻 Additional Limits →Subject Subsets /Systematic reviews：在Medline中被歸類於實證之文獻 5. Limits Guideline文獻 Additional Limits→Publication Types /Guideline以及Practice Guideline 6. Limits RCT and Therapy文獻 Additional Limits→ 同時選擇(1)Publication Types出版類型/randomized controlled trial +(2)Medline特有之Clinical Queries /Therapy (optimized)：同時以clinical queries與Publication Type設定找出臨床治療之RCT文獻 7. . Limits Multicenter study文獻 Additional Limits→Publication Type/Multicenter study：以出版類型查詢Multicenter study文獻 (Multicenter study多家醫學中心聯合實驗) 8. Search Field→勾選Subject Heading Word→ 輸入Multicenter→Search：以Multicenter為關鍵字查詢MeSH 9. 8 and 1：表示MeSH標題中有Multicenter之文獻資料與alzheimer explode，與7: alzheimer explode with publication type multicenter study比較，結果筆數較多 11. Search Tools→Map Term：Multicenter，Explode with or可查出有兩個MeSH標題 主題 Explode / Focus Subheading (Search Tools--Subheading) Publication type:出版品類型符合之MeSH Subject Heading Keyword: 以關鍵字查找符合之MeSH標題，含出版品類型符合之MeSH，出版品類型不符合但內容資訊符合之MeSH

BMJUpdates+    http://bmjupdates.com/index.asp BMJ Update由BMJ Publishing Group提供實證資訊包含Studies與Reviews BMJ蒐集超過100種臨床期刊約5000篇文章篩選每月最重要一至二篇文章 註冊即可使用 Dear Ms. Wang You recently requested to have your username and password for the BMJUpdates system e-mailed to you. Your login information is as follows: Your User Name is: evelynwang Your Password is: 9212009 To login now, click here If you have any questions, please contact us at bmjplus@mcmaster.ca or call 905-525-9140 extension 22994 BMJUpdates+由BMJ Publishing Group從超過110高品質之臨床期刊蒐集相關實證Studies與Reviews 註冊即可線上檢索 利用Advanced Search Search Keyword Select Discipline or Category or Type of Article 可使用AND(大寫)、Trucation*、”” Register now to begin using bmjupdates + http://bmjupdates.com/index.asp

Clinical Evidence   Clinical Evidence 選取基礎醫療常見的臨床問題，收集來自Cochrane Library、MEDLINE、EMBASE 和實證醫學期刊研究的報告結果，提供系統性文獻評論(Systematic Reviews)、隨機取樣的臨床對照試驗(RCTs)及觀察研究(Observational Studies)證據。 Clinical Evidence之使用 使用Sections按主題瀏覽；Full Review List依據A-Z選單瀏覽；站內檢索Search this Site。 Conditions以症狀瀏覽。 瀏覽檢索結果內容：Interventions提供不同療法之利弊比較；About this condition提供症狀/疾病之定義、傳播、風險因子、預後、治療目的、結果、方法；Updates資訊、Guidelines、Reference。  http://clinicalevidence.bmj.com/ceweb/index.jsp

DynaMed      http://www.ebscohost.com/dynamed/ 主題檢索。 A-Z瀏覽。 全文檢索。 學科瀏覽。 檢索結果資訊包含：病況描述(涵蓋 ICD-9/10 codes), 造成原因及危險因子(Causes & Risk Factors), 併發症及相關表徵(Complications & Associated Conditions), 病況歷史(History), 身體狀態(physical), 診斷(Diagnosis), 預後(Prognosis), 治療(Treatment), 防治及篩選(Prevention & Screening), 參考文獻 (包括評論(Reviews)及指南(Guidelines)), 病患資料(Patient Information)等。  Thank you for your interest in DynaMed services, the Internet reference integrating evidence-based medicine with practical information for clinical practice. Your Trial account is good for 30 days(8/20).  To log in using your DynaMed trial account, go to: www.dynamicmedical.com, and then click on "Login to DynaMed". Enter your Trial login ID and Password: User ID:    dmedical Password:   nutrition If you would like to continue using DynaMed on a regular subscription basis, please go to www.dynamicmedical.com, click on "Subscribe Now". Follow the instructions shown there to subscribe to DynaMed. Thank you for choosing DynaMed. DynaMed Support Team http://www.ebscohost.com/dynamed/

DynaMed DynaMed Level 1 (likely reliable) evidence 最有效之報告（以病患導向為主的結論），例：以RCT為主之實驗結果（有效追蹤達80%以上）、來自世代研究初期（inception cohort studies）的預後資訊（prognostic information）、系統性文獻回顧所得之結果。 Level 2 (mid-level) evidence 以病患導向為主的結論而產生的報告，且以科學化的檢視為方法，但是還未到level 1 的標準。例如有效追蹤低於80%的RCT、非隨機對照實驗的研究方式、缺乏足夠參考標準的診斷研究。Level 2並不代表可靠的證據等級。例如荷爾蒙補充療法在大多數的世代研究中都顯示可以降低心血管疾病的發生，但在許多的屬於LEVEL 1等級的RCT實驗中，此一療法不但無法預防心血管疾病，甚至有還可能會增加心血管疾病的風險。 Level 3 (lacking direct) evidence 非科學化的分析研究且不是以病患為導向的結論報告，例如：病例報告、專家意見、及缺乏科學根據的推論

UpToDate     46 http://www.uptodate.com/home/index.html 檢索可以一個或多個關鍵字、詞句或問題。 Ex: treatment of raynaud’s disease in women patient info raynaud’s disease—特別檢索病患資訊 瀏覽檢索結果。 利用Outline快速瀏覽，Summary and Recommendations提供摘要與建議，閱讀實證等級。 檢索歷史回顧。  http://www.uptodate.com/home/index.html

EBM Solution, ACP Journal Club   ACP Journal Club：提供臨床實證醫學文獻資訊 Advanced Search Filter by text type 依據內文類型篩選 檢索包含英文字字尾變化 Search Sets依據類別分類檢索 瀏覽EBM Solution資源    ACP Journal Club's general purpose is to select from the biomedical literature articles that report original studies and systematic reviews that warrant immediate attention by physicians attempting to keep pace with important advances in internal medicine. These articles are summarized in value-added abstracts and commented on by clinical experts. ACP Journal Club提供有品質之生物醫學文獻包括原始文獻與Systematic Review ACP:美國專科醫學學會－內科 The American College of Physicians EBM Solution 實證醫學資料庫(20人版) 收錄資源包括： ACP Journal Club：提供臨床實證醫學文獻資訊 ACP Medicine：實證依據的內容與精彩圖片構成最佳的內科參考電子書，主題包含：臨床必備基本學、心臟血管醫學、皮膚醫學、內分泌學、腸胃病學、血液學、免疫過敏學、傳染病學、新陳代謝、腎臟學、神經病學、腫瘤學、心理學、胸腔學、風濕免疫學、婦產學與其他醫療學等 ACP PIER & AHFS DI Essentials (含ACP's PIER: The Physician's Information and Education Resource)：ACP PIER疾病資料庫，提供臨床及實務上有效的建議預防、診斷、用藥等12種看診時用到的分類；AHFS DI Essentials提供診斷時相關藥物介紹，包括：藥物建議與藥物機轉、劑量、作用、副作用、注意事項等。 AAFP's Conditions A to Z - Patient Information衛教資訊 MedCalc 3000 Complete醫學指數計算公式 Stedman's Medical Dictionary線上醫學字典：EBM Solution的內容反白詞彙，再點選右上角之Stedman’s Lookup便可線上查詢醫學字典。

Essential Evidence Plus(Formerly InfoPOEMs)    Essential Evidence Plus包含EBM Guidelines、Daily POEMs、Cochrane Abstracts 、Selected Practice Guidelines 、Decision Support Calculators 、H&P Calculators 、Diagnostic Test Calculators 、Derm Expert 、E/M Coding 、ICD-9 Lookup Tool。 檢索 依據主題分類瀏覽檢索結果。 依據檢索結果類型瀏覽檢索結果，亦提供依據資源分類瀏覽檢索結果。 檢索結果提示證據等級。 Your Essential Evidence Plus Trial Access Order has been processed, and your account is ready to go! Your trial subscription will be valid until September 24, 2008. Username: evelynwang Password: mbdx9epa EBM Guidelines: Clinical Guidelines POEMS: Synopses Information對於原始文章或評論之簡單描述 100多種期刊上超過3000種主題資訊 Abstracts of the Cochrane Database of Systematic Reviews Selected Practice Guidelines: recommendations for screening監控, diagnostic approaches,診斷 therapeutic interventions治療 and monitoring patients Decision Support Calculators:例如計算BMI History and Physical Test Calculators: Find out the probability of disease based upon the results of clinical evaluation before doing additional testing. 已有之疾病臨床評鑑結果 Diagnostic Test Calculators: The tool offers test characteristics and an estimate of the probability of disease before conducting a test. 疾病特性介紹 Derm Expert: diagnose dermatological conditions診斷皮膚狀況 E/M Coding: determine the most appropriate code to use for Medicare's Evaluation and Management Services ICD-9 Lookup Tool: 國際疾病分類 EBM Guidelines EBM Guidelines is a unique, concise and easy-to-use collection of clinical guidelines for primary care combined with the best available evidence. EBM Guidelines includes 1,000 concise primary care practice guidelines, 3,000+ high quality evidence summaries and a library of 1,000 photographs and images. Continuously updated, EBM Guidelines follows the latest developments in clinical medicine and brings evidence into practice. Example of Use: Clinicians who wish to review the latest and most relevant information about a disease and its treatment will find the information they seek in EBM Guidelines. Daily POEMs Daily POEMs (“Patient-Oriented Evidence that Matters”) are synopses of new evidence carefully filtered for relevance to patient care and evaluated for validity. Daily POEMs emerge from continuous review, grading, and critical appraisal of all 3000+ studies published monthly in more than 100 journals. Using Essential Evidence Plus, you will have complete visibility into the archived collection of 3,500 regularly updated Daily POEMs. Tap into summaries of relevant and essential evidence-based research that are presented in an easy-to-understand format. Quickly identify and understand the information you need and apply the research to your clinical practice! Example of Use: Within three weeks of publication, important study results are incorporated into an Daily POEMs. Instead of reading the 100+ journals that we summarize, simply rely on the POEM evaluation system to find relevant, valid information presented in an easy-to-understand format. The Cochrane Database of Systematic Reviews is considered the gold standard for evidence-based medicine. Essential Evidence Plus includes the latest and most up-to-date summaries of systematic reviews from the Cochrane Library which are the most rigorous and reliable evaluations of medical therapies available. You’ll find summarized evaluations of the world’s best literature on the effectiveness of therapy for 3,000+ clinical problems. Example of Use: In the Cochrane Database you will find answers to questions such as: Are corticosteroids effective in the treatment of acute ischemic stroke? Are “back schools” effective? Should antibiotics be used to treat bacterial vaginosis in pregnant women? Selected Practice Guidelines Essential Evidence Plus’s Selected Practice Guidelines include 1,500 high grade evidence-based guidelines from a variety of sources,. These guidelines often include recommendations for screening, diagnostic approaches, therapeutic interventions and monitoring patients to aid in the total management of patients with specific conditions such as congestive heart failure, otitis media, and others. Example of Use: In Selected Practice Guidelines, you’ll find answers to questions such as: What medical care should be provided most of the time for most patients? What medical care is not effective and should not be used for most patients? Decision Support Calculators Essential Evidence Plus offers 300 Decision Support Calculators. Based on the results of valid and relevant studies, these calculators support the clinical decision making of healthcare professionals by offering risk and probability assessments. These rules and calculators are specifically designed to help estimate the likelihood of a diagnosis, calculate a patient’s risk for disease, estimate a prognosis, or calculate a drug dose. Example of Use: The Decision Support Calculators can help evaluate patients with ankle sprains, estimate the risk of stroke in patients with atrial fibrillation, assist in determining doses of drugs like warfarin, and aid diagnosis in hundreds of other clinical scenarios. History and Physical Test Calculators Essential Evidence Plus’s History and Physical Test Calculators are designed to support clinical decision making! 1,500+ calculators help you determine the likelihood of a patient having a disease based on information gathered during a history and physical evaluation. Find out the probability of disease based upon the results of clinical evaluation before doing additional testing. Example of Use: Clinicians will find answers to hundreds of questions such as: What is the likelihood of strep throat in a patient with tonsillar exudates? In a patient with low back pain, what symptoms are indicators of ankylosing spondylitis? Diagnostic Test Calculators Essential Evidence Plus’s 1,500+ Diagnostic Test Calculators help clinicians choose the best diagnostic test and interpret the test results. The tool offers test characteristics and an estimate of the probability of disease before conducting a test. The calculators also outline the probability of disease based upon test results. You can tailor test result interpretations based on the details of the clinical circumstance. Example of Use: The Diagnostic Test Calculators answers hundreds of questions such as: What is the best test to rule out renal artery stenosis? What is the likelihood to trichomonal infection in women with trichomonas on pap smear? What is the 10-year mortality risk for a patient who smokes and has hypertension? Derm Expert Derm Expert is designed to help clinicians diagnose dermatological conditions utilizing a series of simple steps. The tool contains 1,000 images, along with clear guidelines, to help clinicians quickly and easily identify the right diagnosis. Example of Use: Need to verify the diagnosis of an observed skin condition? Use this tool. E/M Coding The E/M Coding Wizard helps you determine the most appropriate code to use for Medicare's Evaluation and Management Services, and provides an indication of what additional criteria must be met to qualify for the next code level. ICD-9 Lookup Tool The ICD-9 lookup tool provides a user-friendly and intuitive interface for searching the most commonly used ICD-9 diagnosis codes. Each ICD-9 code within Essential Evidence Plus has an associated keyword and in most cases one or more alternate spellings, terms or abbreviations. Generally, ICD-9 codes are simplified for easy reference; for example, “pulmonary embolism” instead of “pulmonary embolism (NOS)”. The ICD-9 lookup tool makes it quick and easy to locate consistent, reliable and accurate diagnosis and procedure codes. Example of Use: Looking for the ICD-9 code for pulmonary embolism? You’ll find it here.  http://www.essentialevidenceplus.com/

Bandolier   http://www.medicine.ox.ac.uk/bandolier/knowledge.html Bandolier Knowledge Library提供實證醫學資料包括：治療主題相關之系統性評論，診斷證據，健康經濟或流行病學等，資訊類型包含：Systematic reviews, meta-analyses, randomised trials, and from high quality observational studies. 關鍵字檢索 A-Z 瀏覽  Bandolier-Evidence based Healthcare Journal The first issue of Bandolier, an independent journal about evidence-based healthcare, written by Oxford scientists, (RAM AND HJM) was printed in February 1994. It has appeared monthly ever since and has become the premier source of evidence based healthcare information in the UK and worldwide for both healthcare professionals and consumers. http://www.medicine.ox.ac.uk/bandolier/knowledge.html

Natural Medicines Comprehensive Database 付費資料庫 Subject-specific database of evidence-based information. Compiled by publishers of Pharmacist's Letter and Prescriber's Letter Herbal medicines, and dietary supplements used in the western world Assesses available evidence; check references for quality of source Natural Standard (available through MedlinePlus) Evidence-based reviews of herbal medicines and supplements. http://www.naturaldatabase.com/ 訂購資料庫 有關草本醫學、西方飲食特殊主題之實證資料庫 提供交互作用、有效性、副作用、安全顧慮、劑量、藥物對營養之影響 提供很多產品之成分資訊，Brand Product Report可以提供產品成分之安全、有效性、藥物交互作用、副作用等資訊 brand product report which is quick summary of safety, effectiveness, drug interactions, and adverse effects for each ingredient contained in the product. Natural Product Effectiveness Checker: 輸入症狀或疾病可查找相關之天然系列產品 Type the name of a condition or disease to find a list of natural products Natural Product/Drug Interaction Checker: 可以查找藥物與天然產品之間的交互作用關係 Find interactions between drugs and natural products The Natural Product /Drug Interaction Checker allows you to enter all of the patient’s conventional drugs and natural products and generate an interaction report with a click of a button. Interactions Ratings are assigned to every drug/natural medicine interaction so you’ll instantly know which ones to be most cautious with. With the Natural Product Effectiveness Checker you can enter any condition or disease and find out which natural products have an evidence-based Effectiveness Rating for that condition. If you’re looking for high-quality brand name products, look for those with the USP Verified mark. Through special partnership with the United States Pharmacopeia (USP), Natural Medicines Comprehensive Database identifies all brand name products that meet these high manufacturing standards. Evidence-Based Monographs Natural Medicines Comprehensive Database is made up of multiple databases. The core database contains the detailed, evidence-based monographs on individual natural ingredients (e.g., glucosamine, echinacea, etc). There are currently almost 1,100 monographs on these individual natural ingredients. http://healthlinks.washington.edu/ebp/ebptools.html#clinicalresearch

US National Guidelines Clearninghouse(NGC) The National Guideline Clearinghouse為美國Evidence-Based Clinical Practice Guidelines資料庫，包含Structured Abstracts ，連結Full-Text Guidelines ，並提供Guideline比較工具。 檢索方式包括： 主題檢索：Detailed Search, Frequent Searches of Frequently Requested Topics 瀏覽By Disease/Condition, Treatment/Intervention, Measures, etc. Guideline比較   NGC美國實證臨床Guideline 提供 NGC offers Syntheses統合文獻論 of selected guidelines that cover similar topic areas, and Expert Commentary評論 on issues of interest and importance to the clinical guideline community.  http://www.ngc.gov/

US National Guidelines Clearninghouse(NGC) Detailed Search可使用Keyword, Disease/Condition, Treatment/Intervention, Guideline Category, Organization, Organization Type, Intended Users, Clinical Specialty, Methods Used to Assess the Quality and Strength of the Evidence, Methods Used to Analyze the Evidence , Methods Used to Formulate the Recommendations , etc. 檢索 Search Select and Add to My Collection Compare Checked Guidelines   

US National Guidelines Clearninghouse(NGC) Guideline Comparison分析比較：Guideline背景資訊Guideline Background、疾病症狀Disease/Condition(S)、分類領域 Guideline Category 、 臨床專科Clinical Specialty、預期中使用者Intended Users、目標Guideline Objective(S)、主要對象Target Population、主要結果Major Outcomes Considered、成本效益Cost Analysis Performed/Reviewed、實驗方法Methods Used To Collect/Select Evidence、證據強度Rating Scheme For The Strength Of the Evidence, etc. Guideline Comparison分析比較：Guideline背景資訊Guideline Background、疾病症狀Disease/Condition(S)、分類領域 Guideline Category 、 臨床專科Clinical Specialty、預期中使用者Intended Users、目標Guideline Objective(S)、主要對象Target Population、主要結果Major Outcomes Considered、成本效益Cost Analysis Performed/Reviewed、實驗方法Methods Used To Collect/Select Evidence、證據強度Rating Scheme For The Strength Of the Evidence, etc.

CMA Infobase: Clinical Practice Guidelines(CPG)  CMA Infobase為加拿大Evidence-Based Clinical Practice Guidelines資料庫。 檢索方式包括： 關鍵字檢索 Advanced Search利用Limits篩選資料，例如：Specialty、Domain如Diagnosis、Treatment 、 Target Gender  CMA Infobase為加拿大之Evidence based clinical practice guidelines Maintained by Canadian Medical Association加拿大醫學學會，超過1200個Guideline Search The CMA Infobase is a public database of evidence-based clinical practice guidelines (CPGs). Maintained by the Canadian Medical Association, it currently includes over 1200 CPGs developed or endorsed by an authorative medical or health organization in Canada. http://www.cma.ca/index.cfm/ci_id/54316/la_id/1.htm

UK National Library of Health(NLH)   http://www.library.nhs.uk/default.aspx

Meta Search Engines

Clin-eguide      實證醫學/臨床資源 藥典 Clin-eguide前身為Skolar MD ClinicalResource@Ovid，包含豐富臨床資源、實證醫學與藥學的整合系統，核心資源包括：Clin-eguide Evidence-Based Medicine、EBM Articles 、National Guideline Clearinghouse 、Aulstraliz/New Zealand Guideline 、Ebook ex: 5-Minute Consult Datebase 、Books@OVID 、Medline 、Nurisng Advisor 、Journal@OVID、 Drug Facts & Comparisons等藥典資源。 自然語言檢索 整合多資源檢索 依照需求資源個別檢索 藥物資訊快速查詢 其他工具：快速診斷、ICD 9、醫學公式速查工具 Clineguide 實證醫學/臨床資源 Clin-eguide Evidence-Based Medicine 導引：National Guideline Clearinghouse Australia / New Zealand Guideline 電子書：5-Minute Consult Database Books@Ovid 資料庫/期刊：Medline Nursing Advisor Journals@Ovid 藥典 Drug Facts & Comparisons A to Z Drug Facts Drug Interaction Facts MedFacts Patient Information – English / Spanish Review of Natural Product 附上Clin-eguide 帳密, 供您參考! 網址 : http://gateway.ovid.com ID/PWS : ncktrain / training

    Clin-eguide檢索結果 可以資源類型分類瀏覽。 並按照相關度顯示。 部分資源可再進一步依據資源特性篩選資料，例如：ERMR Articles可以按照資源項目篩選。 例如：Medline可以依據資料問題種類如Therapy、Diagnosis篩選資料

Clinical Knowledge Summaries(CKS)   CKS提供Clinical Topics, Patient Information, Knowledge Plus which includes Cochrane Library, infectious diseases information, Medico-legal guidance, Feature on primary care laboratory testing, Drug information. 可透過Search All Sections或Search By Single Sections或瀏覽方式使用 CKS為英國National Health Service提供之免費大眾健康系統 前身為PRODIGY 提供實證資訊與針對臨床狀況提供的Know how資訊，目前乃由SCHIN（一個非營利組織）與EBSCO Publishing共同與CKS簽訂合約，提供與NHS使用。  所以嚴格來說，CKS目前是由EBSCO Publishing與SCHIN共同與CKS簽約以協助NHS提供大眾免費使用的。 英國的NHS針對英國英格蘭地區，購買了EBSCO DynaMed的全國版，提供全英格蘭地區所有醫院、診所等醫師使用，有權限之使用者即可透過CKS平台連結與查找DynaMed的資訊。 CKS提供臨床主題Clinical Topics, 衛教資訊Patient Information, Cochrane Library資訊Knowledge Plus which includes Cochrane Library, 傳染疾病資訊infectious diseases information, 醫科法律指引Medico-legal guidance, 試驗與實驗Feature on primary care laboratory testing, 藥物資訊Drug information. CKS適用於: General practitioners, GP registrars Nurses working in Primary Care and Walk-in Centres 一線護理人員 Pharmacists藥師 Medical, nursing and pharmacy students醫護藥學生 Medical librarians醫學圖書館員 It is also a useful resource for: Other healthcare professionals e.g. emergency care practitioners 健康專家如急診 NHS managers NHS管理人員 Accident and emergency departments 急診與急救單位 Educational institutions教育單位 Those involved in the development of care pathways, protocols, patient group directions and clinical management plans Patients病患 可以透過Search All Sections或著By Single Sections Search Browse Topic or Patient Info Clinical Topic資訊包括主題背景 流行病學 造成因子 預後 診斷 處方簽 藥物資訊等 Clinical Topics資訊包括：Background information — definitions, epidemiology, causes, complications and prognosis. Making a diagnosis — symptoms, signs, investigations, differential diagnosis. Quick Answers, Clinical Summaries, Prescriptions, Supporting Evidence, Drug information, Leaflet for Patients. http://cks.library.nhs.uk/home

TRIP Sources searched by trip    TRIP is a subscription resource aimed at delivering the highest quality literature to support clinical practice. Sources searched by trip    TRIP為UK Meta Search Engine 免費資源可以提供高品質的文獻資料來支援臨床實務 answering clinical question 一次可檢索超過55個實證資訊網站 檢索結果可以根據文獻類型如Guideline, Systematic Review來篩選資料 TRIP也可以自動檢所PubMed 檢索果也可以自動分學科 檢索資源包括：Bandolier, Evidence Centre Report, BestBETs, Clinical Evidence, Evidence-Based Medicine, POEMs TRIP (Turning Research Into Practice) | www.tripdatabase.com Meta-search from UK Searches over 55 sites of evidence-based information Includes links to peer-reviewed journals and other publications Subject Search Filter by Publication Type and Specialisation Quick Browse Conclusion About Us List sources searched by Trip http://www.tripdatabase.com/index.html

Meta-Search Engines PrimeEvidence in PrimeAnswers | http://www.primeanswers.org/primeanswers/ Evidence to clinicians at point of care. Focus on adult primary care. Small database (around 500) of evidence-based articles on specific topics from a limited number of difficult-to-access sources SUMSearch | http://sumsearch.uthscsa.edu/ Produced by University of Texas Health Sciences Center, San Antonio Simultaneously searches few free-access sources - PubMed Cochrane Systematic Reviews (within PubMed), National Guideline Clearinghouse and Merck Index Results grouped by reviews, practice guidelines, systematic reviews and research-based articles MD Consult| http://www.mdconsult.com/php/104825338-2/homepage 收錄51本醫學用書、超過80種醫學期刊、10,000篇病患衛教、超過22,000種藥物資訊、美國FDA核准藥物訊息與安全性通告，並提供1,000篇臨床指引，超過50,000張圖片，每週醫藥新知與每周期刊摘要等內容，MD Consult的檢索可支援同義字搜尋、檢索策略轉譯、支援布林邏輯，檢索並提供Refine your search功能將搜尋更為精確化，檢索結果提供Top Results熱門檢索結果與Recommended Results建議檢索結果參考。MD Consult的個人化服務，可透過線上註冊Account，客制化每週醫藥新知的主題、儲存檢索策略以及設定主題之定期通知 First Consult | Medical Topics臨床主題：提供持續更新的實證醫學訊息，近700個臨床主題，包括疾病背景知識、診斷、治療、預後和預防等相關內容，協助決策之支援。 Differential Diagnoses鑑別診斷：依據病患的主訴，提供A-Z字母順序排列的徵兆和症狀列表以及超過1,800種診斷資訊，依據年齡和盛行率進行比較、閱覽。診斷資訊包括：男女性患病比例、分布地點、特徵、患症處、病症模式、加速症狀因子、紓緩症狀因子、併發症等。 Procedures操作程序：超過100種外科及診斷程序，通過視頻剪輯、動畫演譯和關鍵步驟說明，提供清楚明確的操作指導資訊，內容包括：流程指示、禁忌 / 副作用、技術 (Key Steps / Do /Do not)、結果、參考資源(FAQs)。

Problem Patient Intervention Indicator Comparator Outcome Prevention Therapy Diagnosis Prognosis Etiology Harm 實證問題類型與檢索策略 Evidence Based Medicine Toolkit http://www.ebm.med.ualberta.ca/ebm.html

Search Strategies For Therapy/Prevention Step 1. Searching the Disease or Disorder Enter terms best describing the disease or disorder. Possible Subheadings (for broadest coverage, select "all subheadings") Diet Therapy (DH) • Drug Therapy (DT) • Prevention & Control (PC) Radiotherapy (RT) • Rehabilitation (RH) • Surgery (SU) Therapy (TH) • Transplantation (TR) Step 2. Searching for the Intervention Enter terms best describing the intervention. Possible subheadings (for broadest coverage, select "all subheadings") Administration and dosage (AD) • Therapeutic use (TU) • Pharmacology (PD) Step 3. Combine Previous Searches with boolean operator "and" Step 4. Quality Filters for Therapy/Prevention Articles Quick Filter Ovid Medline：(randomized controlled trial or meta analysis).pt. or double blind$.tw. PubMed：randomized controlled trial [ptyp] OR systematic review[ptyp] OR double blind* [word] OR "double-blind-method" [mh] Clinical Queries Alzheimer disease Vitamin E

Search Strategies For Diagnosis Step 1. Searching the Disease or Disorder Enter terms best describing the disease or disorder. Possible Subheadings (for broadest coverage, select "all subheadings") Diagnosis (DI) • Analysis (AN) •Blood (BL) Cerebrospinal Fluid (CF) • Pathology (PA) • Radiography (RA) Radionuclide Imaging (RI) • Ultrasonics (US) • Urine (UR) Step 2. Searching for the Intervention Enter terms best describing the intervention. Possible subheadings (for broadest coverage, select "all subheadings") Diagnostic use (DU) • Analysis (AN) • Blood (BL) Cerebrospinal Fluid (CF) • Urine (UR) Step 3. Combine Previous Searches with boolean operator "and" Step 4. Quality Filters for Diagnosis Articles Quick Filter Ovid Medline：exp "sensitivity and specificity"/ or exp diagnostic errors/ or predictive value$.tw. PubMed："sensitivity and specificity" [mh] OR diagnostic errors [mh] OR predictive value* [word] Clinical Queries Cerebrospinal Fluid 腦脊液蛋白 Ultrasonics 超聲波;超聲波學 Urine 尿 Radiography X光照相術 Radionuclide Imaging物理放射性核種影像

Search Strategies For Prognosis Step 1. Searching the Disease or Disorder Enter terms best describing the disease or disorder. Possible Subheadings (for broadest coverage, select "all subheadings") Classification (CL) Complications (CO) Diagnosis (DI) Epidemiology (EP) Etiology (ET) Mortality (MO) Physiopathology (PP) Step 2. Combine Previous Searches with boolean operator "and" Step 3. Quality Filters for Prognosis Articles Quick filter Ovid Medline：exp cohort studies/ or exp survival analysis/ PubMed：Cohort studies [mh] OR survival analysis [mh] Clinical Queries Epidemiology流行病學 Etiology病原學 Mortality死亡數;死亡率 Physiopathology

Search Strategies For Harm/Etiology Step 1. Searching the Suggested Source of Harm Enter terms best describing the source of harm. Possible Subheadings (for broadest coverage, select "all subheadings") Adverse Effects (AE) • Contraindications (CT) Poisoning (PO) • Toxicity (TO) Mortality (MO) (not always an option) Step 2. Searching for the Relevant Disorder/ Anticipated Outcome Enter terms best describing the disease or disorder/outcome. Abnormalities (AB) • Chemically Induced (CI) • Epidemiology (EP) Etiology (ET) • Mortality (MO) • Transmission (TM) Step 3. Combine Previous Searches with boolean operator "and" Step 4. Quality Filters for Harm/Etiology Articles Quick Filter Ovid Medline：case control studies/ or cohort studies/ or risk/ PubMed：case-control studies [mh:noexp] OR cohort studies [mh:noexp] Clinical Queries Adverse Effects 負作用 Contraindication禁忌症 Poisoning毒;毒藥;毒物 Toxicity毒性,毒力 Abnormalities變態;畸形 Chemically Induced Epidemiology流行病學 Etiology病原學 Mortality死亡數;死亡率 Transmission傳播 Search Tools—Map Term Explode Case control studies

Search Strategies For Others Practice Guideline Ovid Medline：Additional Limits ---> Publication type---> Limit to Practice Guidelines Pubmed：Limits Section -->Under Type of Article -->Limit to Practice Guideline Systematic Review Ovid Medline with Ovid EBMR：Limits ---> EBM Reviews ---> Limit to Top Reviews (Cochrane) Ovid Medline：Additional Limits ---> Subject Subsets --> Limit to Systematic Review Pubmed：Clinical Queries Section--> Search using Systematic Reviews search box Articles on Economic Analysis Cochrane Library includes and Economic Evaluations database that can be searched by Critically Appraised Economic Evaluations Combine Searches as below with boolean operator "and" Ovid Medline： 精確查詢：ec.fs (adding the subheading economics to your search terms ) cost$ or economic$ Pubmed：cost$ or economic$ Quick Filters Ovid Medline：Additional Limits Section --->Clinical Queries box-->limit to ecomomics Pubmed：MeSH Database Section--> Search using the exact phrase "cost and cost analysis"

萬用字元符號於每個資料庫定義不同，需針對個別資料庫設定而使用 實用技巧-布林邏輯與運算元 萬用字元符號於每個資料庫定義不同，需針對個別資料庫設定而使用 運算元 OVID範例 OR (pregnancy or birth).ti. 1 or 2 or 3 or 5＝or/1,2,3,5＝or/1-3,5 AND (pregnancy and birth).ti. 1 and 2 and 3 and 5＝and/1,2,3,5＝and/1-3,5 Not 排除 (education not patient education).ti. safety not patient safety.ti.⇒safety.mp not patient safety.ti safety not patient safety⇒safety.mp not patient safety.mp 1 not 2 AdjN 指定距離 physician adj5 relationship (information adj3 retrieval).tw. Freq 關鍵字出現頻率 blood pressure.ab./freq=10 (information adj3 retrieval).tw./freq=5 一次僅指定一個欄位；且組合型欄位如SO無法使用Freq. 成功大學圖書館醫學院分館，2008-07-09(三)「實證醫學/護理在Medline」教育訓練會，飛資得資訊股份有限公司李紹迪小姐主講。

實用技巧-切截字與萬用字元 切截字：$或* 可以查出所有字首 相同之關鍵字 depress $depress, depressive, depressants, depressor…… rat$rat , rate, rationalize, ratify…… 字母數的關鍵字 字尾不少於特定 查出有相同字首且 dog$1 dog, dogs…（但是不會查dogma） 其他字元：#和?( 前方最少需2個字元以上) #：關鍵字有一個字母不確定或單複數變化 wom#n woman、women dog#  dogs（但是不會查到dog） ?：美式與英式英文的差異或不確定關鍵字是否包含該字母 colo?r  color, colour dog? dog, dogs 成功大學圖書館醫學院分館，2008-07-09(三)「實證醫學/護理在Medline」教育訓練會，飛資得資訊股份有限公司李紹迪小姐主講。