醫學文獻查找密技報你知：Ovid Medline & PubMED 飛資得醫學資訊 業務代表：陳永祥先生 TEL:02-2658-2223(分機:508) Email:tesochen@flysheet.com.tw

Occult Blood VS Sigmoidoscopy 臨床問題或研究方向 Q：兩種用於大腸癌篩檢(Intestinal Neoplasms)的方式之比較? (糞便潛血檢查 VS 乙狀結腸內視鏡檢查) Occult Blood VS Sigmoidoscopy *Colonic Neoplasms / di [Diagnosis]結腸腫瘤 *Occult Blood Rectal Neoplasms 直腸癌 Sigmoidoscopy乙狀結腸鏡檢查

重點整理 將臨床問題以PICO方式呈現 活用關鍵詞檢索的技巧 善用主題詞(MeSH)的檢索方式 兼顧完整與精確的文獻檢索 (合併關鍵詞及主題詞檢索) 多走一里路：用Limit選擇特定的文獻需求 選擇使用資源 Medline or PubMed

重點一： 將臨床問題以PICO方式呈現

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 在實證醫學的五步驟，大家都很熟悉。今天我們所要講的就是，當現在的醫護人員利用PICO的方式來形成一個可以回答的臨床問題後，要如何運用PICO來搜尋資料。 資料來源參考：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。

P I C O 形成一個可以回答的臨床問題 PICO的好處：聚焦問題，容易找到關鍵字。 Patient or Problem 病人是誰，有甚麼問題？ P Intervention or Indicator 想要作哪些觀察、診斷或治療？ I Comparator 有無其他方式或選擇? C Outcome 效果是甚麼?或是預計的結果？ O PICO的好處：聚焦問題，容易找到關鍵字。 分辨臨床問題的型態，如治療、傷害、診斷、預後與病因等類別。 協助瞭解何者是最好且最適合的研究設計 據此而產生的研究結果才是最佳證據等級的文獻。

P 懷疑罹患大腸癌 Intestinal Neoplasms I 糞便潛血檢查 Occult Blood C 乙狀結腸內視鏡檢查 將臨床問題以PICO方式呈現 P 懷疑罹患大腸癌 Intestinal Neoplasms I 糞便潛血檢查 Occult Blood C 乙狀結腸內視鏡檢查 Sigmoidoscopy O 提高篩檢精確率 Diarrhea AND Tube feeding AND Probiotics AND diarrhea

重點二： 活用關鍵詞檢索的技巧

Basic Search 基本檢索 適用於： 查詢方式 建議選項 資料庫使用新手 迅速查詢相關文獻 輸入所有查詢內容 自然語言智慧搜尋 輸入所有的關鍵字 一個完整的句子 複製某篇文章的篇名 自然語言智慧搜尋 (Natural Language Processing) 建議選項 Check Spelling 提示拼字錯誤 Include Related Terms 同義之字/詞/片語查詢 單複數與詞性變化形查詢 英美語系之異體字查詢 專業縮寫/全寫查詢 可對應之標題詞查詢 treatment for childhood obesity

在Basic Search找到最佳檢索結果之技巧 檢索簡潔化 排除無關緊要的形容用詞 多使用名詞而非動詞 名詞可說是一個概念最原始的型態, 比較容易被辨識且代表的意義不會含糊不清. 相關研究指出在檢索時若使用名詞作為檢索詞彙, 可以得到品質較佳的檢索結果 善用布林邏輯(AND OR NOT)

布林邏輯: AND 地瓜 營養 地 瓜 營 養 AND

布林邏輯: OR 地瓜 蕃藷 地 瓜 蕃 薯 OR

布林邏輯: NOT 地瓜 地 瓜 種 植 NOT

關鍵詞搜尋(Basic Search)三步驟 1 Keyword Search 2 Use AND OR NOT 3 Limit 5 Stars to Read

重點三： 善用主題詞(MeSH)的檢索方式

關於醫學標題MeSH MeSH(Medical Subject Heading) NLM用以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內容之控制語彙表，亦為MEDLINE/PubMED資料庫主題檢索的索引典。 每篇文獻會被賦予數個主要MeSH與次要MeSH 標示為 主要MeSH MeSH 搭配前方MeSH的副標題

樹狀結構MeSH： - 以階層方式（hierarchical）展現廣義詞和狹義詞間的關係 Broader Term 廣義主題  表示同時查詢狹義主題 Narrower Term 狹義主題 屬於同一個Broader Term的相關主題

每個MeSH會有對應的副標題可做進階分類

使用副標題精確檢索內容  

主題詞(MeSH)檢索重點整理 善用MeSH標題比對功能 使用MeSH Tree來擴展或縮小查詢範圍 善用Focus來篩選重要的文獻 可以協助找出符合主題的資料 無須煩惱縮寫或別名問題 使用MeSH Tree來擴展或縮小查詢範圍 MeSH Tree可顯示標題間分類的層級關係。最上層顯示者，表示該標題詞所代表的主題意涵較廣（generic），而愈下層顯示者，則表示所代表的主題意涵愈為特異（specific）。 善用Focus來篩選重要的文獻 善用Explode來擴展相關主題 使用SubHeading(副標題)來精確查詢方向

主題搜尋(Advanced Search)三步驟 1 MeSH Term Search 2 Choice SubHeading 3 Combined MeSH Term Result

重點四： 善用Limit選擇特定的文獻需求

善用Limit查詢所需資料 常用條件 EBM可用 年齡層、期刊類別 指定實證文獻 文獻類型 臨床問題種類 Systematic Review Publication Type MeSH 臨床問題種類 Clinical Queries 年齡層 期刊類別 動物 發表語言 2b.出版類型 研究範疇 3.問題種類 文獻索引 2a.特定主題類別

--------Clinical Queries-------- 與實證有關之文獻類型 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 使用Limits/Additional Limits中的Publication Type篩選，例如RCTs 使用Map Term to Subject Heading查詢，再以And交集，如Cohorts Studies

嚴格評讀證據之效度與重要性 --判讀文獻等級- Level Therapy/Prevention, Aetiology/Harm  1a Systematic review of RCTs + Meta-Analysis  1b Randomized controlled trial (RCT) 1c ‘All-or-none’ 2a Systematic review of cohort studies  2b Cohort study or poor RCT 2c ‘Outcomes’ research ; Ecological studies 3a Systematic review of case-control studies  3b Case-control study  4 Case series 5 Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles" Level Therapy/Prevention, Aetiology/Harm 1a Systematic review of RCTs + Meta-Analysis 1b Randomized controlled trial (RCT) 1c ‘All-or-none’ 2a Systematic review of cohort studies 2b Cohort study or poor RCT 2c ‘Outcomes’ research 3a Systematic review of case-control studies 3b Case-control study 4 Case series 5 Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles" 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 學員可以只先記紅色字 all-or- none 全有或全無: all patients died before the drug became available, but some now survive on it; or when some patients died before the drug became available, but none now die on it. 無論使用何種研究方法，但其研究結果為完全正面、完全負面或完全無效果 Outcomes research is a broad umbrella term without a consistent definition. However it tends to describe research that is concerned with the effectiveness of public-health interventions and health services; that is, the outcomes of these services. Attention is frequently focused on the affected individual − with measures such as quality of life and preferences − but outcomes research may also refer to effectiveness of health-care delivery, with measures such as cost-effectiveness, health status and disease burden. The present review details the historical background of outcomes research to reveal the origins of its diversity. The value and relevance of outcomes research, commonly employed research techniques and examples of recent publications in the area are also discussed. (Intern Med J 2003; 33: 110−118)   WHAT IS OUTCOMES RESEARCH?"Outcomes research" is a term developed in the past 15 years to describe clinical research concerning the outcomes of medical care (1, 2). Outcomes, broadly defined, can include any variable used to assess the effect of some medical treatment or intervention. "Outcomes research," however, connotes clinical research that focuses less on physiology or biochemical processes and more on clinical end points directly relevant to patients and society: mortality, quality of life, health status, functional status, and costs of care (3, 4). Outcomes research examines the effectiveness of treatment in real clinical settings of heterogeneous patient populations with barriers to treatment rather than the efficacy of treatment in the more controlled research settings with carefully selected, motivated subjects. In addition, outcomes research is concerned with a broad range of issues touching on all aspects of health care delivery, from the clinical encounter between patient and clinician to questions of the organization, financing, and regulation of the health care system. While large, population-based randomized controlled studies using outcomes important to patients (often called "effectiveness trials") are a type of outcomes research, much of outcomes research relies on observational, nonrandomized designs (5). In fact, outcomes research performed by trainees will likely be observational research because of the time and expense involved in performing effectiveness randomized controlled trials. There is a growing recognition of the need for outcomes research, both observational and experimental, to understand and improve the way health care is delivered throughout our society. Although the terms "outcomes research," "clinical epidemiology," and "health services research" have overlapping definitions, we use "outcomes research" in a broad way to include much of the disciplines of clinical epidemiology and health services research. Therefore, we define outcomes research as clinical research attempting to understand and improve the outcomes of illness and medical treatment by focusing on those outcomes important to patients and society. Although it is difficult to draw a sharp line distinguishing outcomes research from other clinical research, many important types of clinical studies are clearly not outcomes studies. For example, small clinical trials using physiologic or biochemical end points are not outcomes research. Nonetheless, faculty performing these other types of clinical research have much to contribute to training outcomes researchers, and trainees interested in other types of clinical research could benefit from many of the tools taught to outcomes researchers. Pulmonary clinicians have been doing outcomes research for at least 25 years. As one example, the Nocturnal Oxygen Therapy Trial in the 1970s used quality of life, as well as survival, as an outcome in a large effectiveness trial to demonstrate the value of oxygen therapy for patients with COPD and hypoxemia (6). The investigators used this study to describe the effect of COPD on the quality of life in these patients (7). Since that time, there has been a large body of work assessing the quality of life and functional status of patients with COPD and asthma and using these measures to determine the effectiveness of treatments (8). Critical care researchers have been among the leaders in assessing outcomes of medical care and performing risk adjustment to control for severity of illness. The APACHE score was one of the earliest validated systems to assess risk, control for severity of illness, and predict outcome (14), and the APACHE III remains one of the most comprehensive and accurate risk adjustment systems available (15). Assessing outcomes and predictors of outcomes in critical care has been an important and vital area of research for three decades. http://ajrccm.atsjournals.org/cgi/content/full/157/4/1012 http://www.ahrq.gov/clinic/outfact.htm 5: 未經考證之專家個人意見, 基礎研究, 細胞實驗, 生理實驗, 動物實驗…的結果 證據力弱 設計薄弱 偏差多 表濃縮自: Oxford Centre for EBM Levels of Evidence(第1版) http://www.cebm.net/index.aspx?o=1047 第2版亦於 2010.6上線: http://www.cebm.net/index.aspx?o=5653

重點五： 兼顧完整與精確的文獻檢索

兼顧完整與精確的文獻檢索步驟 選擇 Basic Search(基本檢索) – 最快，最新 完整輸入查詢的主題/概念/問題 Filter (篩選) 5 starts的結果 加入檢索歷史 (Add to History) (包含尚未提供MeSH主題之最新文獻) 選擇Advance Search(進階檢索) – 最精準 每一個關鍵字主題個別單一查詢 將每一主題的查詢結果以And交集 善用Limit功能篩選查詢結果 將A與B的結果以OR聯集，獲得所有結果

PubMed Search

PubMed簡介 PubMed為美國國家醫學圖書館中的美國國家生物資訊中心（National Center for Biotechnology Information, 簡稱NCBI）所研發的生物醫學主題相關文獻的資料庫檢索系統。 收錄自1950年起的生命科學相關文獻，並收錄資訊科學、航太科學等其他學科文獻。 免費書目資料檢索服務，不斷更新資源 除收錄美國文獻外，另收80多國期刊 提供部分免費及付費全文連結服務，並包含即將出版的醫學文獻。

PubMed 首頁 NCBI各類型資料庫 進階檢索 檢索歷史 MeSH 辭彙檢索 篩選實證 醫學資料 查詢期刊全稱

PubMed文獻書目顯示狀態 文獻書目資料已經經過審核 MEDLINE OLDMEDLINE Citations 收錄年代:1966-Present 內容有MeSH Term 書目資訊會加註[PubMed- indexed for MEDLINE] OLDMEDLINE Citations 收錄年代:1950-1965 內容未有MeSH Term且不提供摘要 書目資訊會加註[PubMed- OLD MEDLINE for Pre1966] PubMed not Medline 非生物醫學類或非生命科學主題的文獻 書目資訊會加註[PubMed]

文獻書目顯示狀態 文獻書目資料尚未被審核 Publisher Supplied In Process Citation 由出版社提供即時或未出版之書目資料，但並非所有書目資料皆會收錄至MEDLINE 書目資訊會加註[PubMed-as supplied by publisher] In Process Citation 資料每日增加，但尚未被專業人員處理 書目資訊會加註[PubMed-in Process]

MeSH 由美國國家醫學圖書館(NLM)建置， 全稱：「Medical Subject Headings」，一套生物醫學領域的主題詞表，每個主題詞 (以下稱 MeSH Term) 代表特定的主題範疇。 對於同一概念採用固定表達方式，方便陳述資料之主題內涵並提供檢索。(使用者可選擇正確主題詞彙檢索，找尋同義詞、廣義詞、狹義詞) MeSH共有23,885的標題，分為16大類，每大類採取樹狀結構，下層細分小標題，顯現標題間層屬關係。 上層顯示此標題詞涵義較廣(廣義詞) 下層顯示此標題越專精(狹義詞) 資料來源:臺大圖書館參考服務部落格， http://tul.blog.ntu.edu.tw/archives/7180

Neoplasms結構圖 「Ovarian Cysts」(卵巢囊腫)這個詞依序是隸屬於「Diseases Category」(疾病)→「Neoplasms」(腫瘤)→「Cysts」(囊腫)，其下還有「Polycystic ovary syndrome」(多囊卵巢綜合徵) 等更專指的詞彙。

副標題 縮小檢索範圍 MeSH概念，檢索PubMed有兩種選擇: 1.PubMed:檢索文章中主要標題及次要標題，即包含這個概念的所有文獻 2.PubMed-Major Topic:只檢索文章主要標題 建議可同時查詢的標題

＊號為此篇文章主要Major MeSH Term

常用特定欄位檢索 篇名中任一字 title [ti] 篇名或摘要 title/abstract [tiab] 作者機構 檢索內容 英文全稱 使用方法 篇名中任一字 title [ti] 篇名或摘要 title/abstract [tiab] 作者機構 affiliation [ad] 作者姓名 author [au] MeSH主要標題 MeSH Major Topic [majr] PubMed號碼 pmid [pmid] 任何關鍵字 text word [tw]

限制檢索選擇適合文獻 1.Article types(文獻類型) Clinical trail Meta-Analysis Randomized Controlled Trail(RCT) Systematic Reviews 2. Text availability(文章取得) 摘要、免費全文、全文 3.Species(研究對象) 人類or 動物 4.Publication dates(出版日期) 5.Ages(研究對象年齡) 6.Subject(主題)

題名 作者 提供免費文章 期刊名 年代 2013 卷期33(2) 頁數243-9 資料收錄在MeSH資料庫 提供免費文章 書目處理中無MeSH

No abstract available沒有摘要 Epub只出版電子版 電子早於紙本出版 在PubMed專用號碼（檢索點） No abstract available沒有摘要 Epub只出版電子版

Q：檢索骨髓移植(Bone Marrow Transplantation)的實證醫學文獻? 臨床問題或研究方向 Q：檢索骨髓移植(Bone Marrow Transplantation)的實證醫學文獻? (限定Meta Analysis、Randomized Controlled Trial、Systematic Reviews文獻) 查詢骨髓移植：Bone Marrow Transplantation有主題詞，並Focus Limit 1為meta analysis or randomized controlled trial or systematic reviews的實證醫學文獻 將2 or 3找聯集 約1000筆。

Q：檢索以阿茲息(Aricept)藥物治療老年失智症(Alzheimer Disease)的文獻? 臨床問題或研究方向 Q：檢索以阿茲息(Aricept)藥物治療老年失智症(Alzheimer Disease)的文獻? 查詢骨髓移植：Bone Marrow Transplantation有主題詞，並Focus Limit 1為meta analysis or randomized controlled trial or systematic reviews的實證醫學文獻 將2 or 3找聯集 約1000筆。

Q：檢索從經濟學(Economics)的角度研究試管嬰兒(Fertilization in vitro)的文獻? 臨床問題或研究方向 Q：檢索從經濟學(Economics)的角度研究試管嬰兒(Fertilization in vitro)的文獻? 查詢骨髓移植：Bone Marrow Transplantation有主題詞，並Focus Limit 1為meta analysis or randomized controlled trial or systematic reviews的實證醫學文獻 將2 or 3找聯集 約1000筆。

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