實證醫學文獻搜尋 Acquire 圖書館參考館員(正職)‧實證醫學中心委員(兼差)

Presentation on theme: "實證醫學文獻搜尋 Acquire 圖書館參考館員(正職)‧實證醫學中心委員(兼差)"— Presentation transcript:

1 實證醫學文獻搜尋 Acquire 方靜如 @馬偕紀念醫院 圖書館參考館員(正職)‧實證醫學中心委員(兼差)
實證醫學文獻搜尋暨圖書館推廣經驗分享研討會 慈濟技術學院‧ :00-11:00, 11:10-12:00 實證醫學文獻搜尋 Acquire 圖書館參考館員(正職)‧實證醫學中心委員(兼差) (02) #3253

2 實證醫學5步驟 (5 A) 1. Ask 詢問可分析的問題 5. Audit 檢討提供的決定 Ask PICO 4. Apply
應用在我的病人族群 2. Acquire 找尋最佳的證據 3. Appraise 嚴格的評讀證據

3 臨床情境 1 你的好友曉竹今年25歲，新婚不久便懷孕，面對眾說紛紜的生產方式選擇，感到非常焦慮與無所適從。
Baby’s head 你的好友曉竹今年25歲，新婚不久便懷孕，面對眾說紛紜的生產方式選擇，感到非常焦慮與無所適從。 她的同事提到：「我生第一胎時，醫師將我的會陰喀嚓一聲剪開，然後吸出胎頭，嚇死我了，但不切開又很擔心對小baby的傷害。我生產後會陰疼痛好久喔! 」 曉竹想請教你，自然產時會陰要不要切開？尤其對小寶寶切與不切的好處和壞處有什麼差別嗎? Episiotomy Anus Kilpatrick S, Garrison E. Figure Cutting a midline episiotomy. In: Gabbe SG et al., ed. Normal labor and delivery. New York: Churchill Livingstone; 2007:319.

4 why PICO 架構化問題的方法 聚焦問題重點 轉化為檢索用語 (即關鍵字) 促使檢索資料庫有效率與完整

5 how PICO P I C O Question : 一個問句簡潔有力表達臨床特定問題 Patient/Problem
Intervention C Comparison O Outcomes Type 誰是病人: 性別, 年齡, 種族, 懷孕, 肝腎功能, 病史… 何種疾病或症狀 關注的 治療:方式, 劑量, 頻率… 診斷工具 暴露因子 對照的 治療:方式, 劑量, 頻率… (ex. Placebo) 診斷工具 (ex. Gold standard) 暴露因子 臨床關注、對病患有意義可測量的結果 安全性: 死亡, 副作用… 有效性: 改善症狀, 增加存活, 避免危險因子… □ Diagnosis □ Therapy □ Prognosis □ Harm □ Etiology 問題型態牽涉到什麼才是此類問題的最佳研究設計、最佳證據等級文獻

6 PICO :將臨床問題架構化 P I C O 自然產 vaginal delivery 常規性使用會陰切開術
自然產期間常規使用會陰切開術對於新生兒出生結果並沒有好處? Is there no benfit on neonatal outcomes to routine use of episiotomy during vaginal delivery? P 自然產 vaginal delivery I 常規性使用會陰切開術 routine episiotomy C 限制性使用會陰切開術 restrictive episiotomy O 新生兒出生結果 neonatal outcomes (Apgar score, neonatal resuscitation, neonatal trauma) Type □ Diagnosis □ Therapy □ Prognosis □ Harm □ Etiology 

7 臨床情境 2 64歲鄰居阿春奶奶想要飛去美國參加她孫女的畢業典禮，但她擔心長途飛行可能會發生經濟艙症候群，也就是深部靜脈血栓(DVT)。
她穿彈性襪可以預防，阿春奶奶她詢問在醫院工作的你，這種方法有效嗎?

8 學習單: 尋找證據

9 搜尋實證障礙 vs. 策略 (大綱) 只找到/看到片面現象(B)，而非貼近事實(A) 資源太多，不知道從何下手 不知道怎麼定義關鍵字
FIRST: Filtered Resources (EBM Database: UpToDate) PLUS: Unfiltered Resources (PubMed) 無頭緒: Meta Search、Google (Scholar) 不知道怎麼定義關鍵字 PICO: 同義字 + 控制詞彙(MeSH) 不熟悉資料庫搜尋技巧 資訊檢索概念 + 資料庫演練 找到一些文章，但哪些才是重要的 證據等級 Levels of Evidence

10 證據等級 Levels of Evidence
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" 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" 證據力強 設計嚴謹 偏差少 等級可能因研究的品質、或間接性佐證等因素，而被降低，反之亦可能升高 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) 第2版亦於 上線:

11 Randomized Controlled Trial (RCT) 隨機對照試驗
有病 沒病 鏈黴素 有病 沒病 安慰劑 結核病人 有介入‧有對照‧有隨機 SUNY Downstate EBM Tutorial: ,

12 觀察性研究方法。大多是前瞻性，也有少數是回溯性。
Cohort Study 世代研究 肺癌 無肺癌 檢驗有(或無)暴露在某種介入的子群組之間差異 抽菸者 一群界定清楚的人 A Cohort Study is a study in which patients who presently have a certain condition and/or receive a particular treatment are followed over time and compared with another group who are not affected by the condition under investigation. For instance, since a randomized controlled study to test the effect of smoking on health would be unethical, a reasonable alternative would be a study that identifies two groups, a group of people who smoke and a group of people who do not, and follows them forward through time to see what health problems they develop. Cohort studies are not as reliable as randomized controlled studies, since the two groups may differ in ways other than in the variable under study. For example, if the subjects who smoke tend to have less money than the non-smokers, and thus have less access to health care, that would exaggerate the difference between the two groups. The main problem with cohort studies, however, is that they can end up taking a very long time, since the researchers have to wait for the conditions of interest to develop. Physicians are, of course, anxious to have meaningful results as soon as possible, but another disadvantage with long studies is that things tend to change over the course of the study. People die, move away, or develop other conditions, new and promising treatments arise, and so on. Even so, cohort studies are generally preferred to case control studies , since they involve far fewer statistical problems and generally produce more reliable answers. 肺癌 無肺癌 非抽菸者 觀察性研究方法。大多是前瞻性，也有少數是回溯性。 SUNY Downstate EBM Tutorial: ,

13 Case Control Study 病例對照研究
癌症病人 抽菸者 非抽菸者 非癌症病人 抽菸者 非抽菸者 統計顯示：肺癌病人中有較高比例是沒有大學學歷而且他們抽菸 => 推論:取得大學學歷可以減少得到肺癌的機率?! SUNY Downstate EBM Tutorial: ,

14 Case Series and Case Report 病例系列與病例報告
SUNY Downstate EBM Tutorial: ,

15 Systematic Review + Meta-Analysis 系統性評論 + 統合分析
(通常是RCT) 提出一個特定的臨床問題 執行完整文獻搜尋 排除不適用的研究 評析設計良好且適用的研究 歸結臨床應用上的可行建議 Systematic Review 基於systematic review 將個別研究數據進行統計學量化分析 歸結出一個證據力更強的結論 Unsystematic narrative “review”: 混合個人意見和證據，而證據搜集也常岀自reviewer個人的選擇 SUNY Downstate EBM Tutorial: ,

16 Cochrane Reviews (範例)

17 Characteristics of included studies (特性與評析)
Characteristics of excluded studies (排除理由)

18 Analyses

19 實證醫學資源類型與特性 組織實證醫學資源的模式 (EBM Resources Pyramid)
Haynes Model: 4S > 5S > 6S EBM Pyramid & Generator by Dartmouth Coll. & Yale Univ.: Jan Glover, David Izzo, Karen Odato and Lei Wang. 馬偕圖書館網站採用

20 Haynes Model: 4S > 5S > 6S
DiCenso A, Bayley L, Haynes RB. Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. ACP J Club 2009;151:JC3-2, JC3-3. Filtered, Pre-appraised! Systems Systems Synopses Syntheses Studies 5S: 2006 Summaries Summaries UpToDate, FirstConsult, ACP PIER Systems Synopses Syntheses Studies 4S: 2001 Synopses of Syntheses ACP J C Syntheses Systematic Reviews Synopses of Studies ACP J C Studies 6S: 2009 Unfiltered, Unappraised!

21 馬偕醫院圖書館 http://library.mmh.org.tw 實證醫學資源金字塔 http://library.mmh.org.tw/EBMR.htm
Cochrane Reviews PubMed: Systematic Reviews 資訊精萃 簡單的關鍵字 省時搜尋與評讀 快速支援決策 由Unfiltered積累  UpToDate  DynaMed  Clin Evidence FirstConsult ACP PIER  ACP J Club, EBM J (PubMed) PubMed, EMBASE CINAHL Cochrane: Clin Trials PEDRo, OTSeeker 華藝, 臺灣期刊論文 文獻雜多 完整的關鍵字 費時搜尋與評讀 注重檢索技巧 資訊新穎

22 Critical-Appraised Individual Articles 對單篇研究或回顧性文獻作摘要與評述的期刊
ACP Journal Club Evidence Based Medicine Bandolier Evidence-Based Cardiovascular Medicine Evidence-Based Dentistry Evidence-Based Eye Care Evidence-Based Gastroenterology Evidence-Based Health Policy & Management Evidence-Based Healthcare Evidence-Based Mental Health Evidence-Based Nursing Evidence-Based Obstetrics & Gynecology Evidence-Based Oncology International Journal of Evidence-Based Healthcare Journal of Evidence Based Dental Practice … 濃縮單篇原始研究為精簡EBM評論

23 濃縮 9 頁原始研究為1-2頁EBM評論 原始研究 發現 實務與研究之影響 背景 評論 研究方法 參考書目
Evid Based Nurs 2011;14: 。Care of the older person. Randomised controlled trial A music-based multitask exercise programme is a promising intervention for improving gait, balance and fall risk in older adults. Lesley Brown, Natalie de Bruin 濃縮 9 頁原始研究為1-2頁EBM評論 原始研究 發現 實務與研究之影響 背景 評論 研究方法 參考書目

24 Unfiltered Resoureces ex.專科原始文獻資料庫
物理治療 職能治療 心理治療 (腦損傷) 語言治療

25

26 Critically-Appraised Topics 實證主題評論資料庫

27 UpToDate :Search 依相關性排序 episiotomy
輸入單字(hoarseness)、縮寫(PPI)、片語(gastroesophageal reflux )、字頭(gastro)、詞或句子 不要輸入布林邏輯: AND、OR episiotomy 依相關性排序

28 UpToDate :Result 內文 大綱 Recommendation grades
1. 強烈推薦：大部分病人接受此治療，好處明顯大於傷害 2. 薄弱推薦：好壞處參半或不明確，須依個別病人做決策 Evidence grades A. 高品質證據：來自執行良好RCT或提供壓倒性結果的其他研究 B. 中品質證據：來自有瑕疵的RCTs(如結果不一致、方法學上缺失)、或提供強烈證據的其他研究(如執行良好的觀察性研究) C. 低品質證據：來自觀察性研究、或有嚴重瑕疵的RCTs Recommendation grades 1. 表示強烈推薦，大部分病人接受此治療，好處明顯大於傷害 Strong recommendation: Benefits clearly outweigh the risks and burdens (or vice versa) for most, if not all, patients 2 : 表示不充份推薦，因為好壞處參半或不明確 Weak recommendation: Benefits and risks closely balanced and/or uncertain Evidence grades A.高品質證據: 引用的文獻證據來自執行良好RCT或提供壓倒性結果的其他研究 High-quality evidence: Consistent evidence from randomized trials, or overwhelming evidence of some other form B.中品質證據:引用的文獻證據來自有些微瑕疵的RCTs(例如不一致的結果、方法學上的缺失)、或提供強烈證據的其他研究(如執行良好的觀察性研究) Moderate-quality evidence: Evidence from randomized trials with important limitations, or very strong evidence of some other form C.低品質證據:引用的文獻證據來自觀察性研究、或有嚴重瑕疵的RCTs Low-quality evidence: Evidence from observational studies, unsystematic clinical observations, or from randomized trials with serious flaws 部份會提供推薦與證據等級

29 UpToDate :Result Recommendation grades 1. 表示強烈推薦，大部分病人接受此治療，好處明顯大於傷害
Strong recommendation: Benefits clearly outweigh the risks and burdens (or vice versa) for most, if not all, patients 2 : 表示不充份推薦，因為好壞處參半或不明確 Weak recommendation: Benefits and risks closely balanced and/or uncertain Evidence grades A.高品質證據: 引用的文獻證據來自執行良好RCT或提供壓倒性結果的其他研究 High-quality evidence: Consistent evidence from randomized trials, or overwhelming evidence of some other form B.中品質證據:引用的文獻證據來自有些微瑕疵的RCTs(例如不一致的結果、方法學上的缺失)、或提供強烈證據的其他研究(如執行良好的觀察性研究) Moderate-quality evidence: Evidence from randomized trials with important limitations, or very strong evidence of some other form C.低品質證據:引用的文獻證據來自觀察性研究、或有嚴重瑕疵的RCTs Low-quality evidence: Evidence from observational studies, unsystematic clinical observations, or from randomized trials with serious flaws

30 Critically-Appraised Topics :特性一覽
資料庫 證據標示 特色 限制 更新 UpToDate ? 疾病/藥物: 8,300處置 [註] 推薦: 1-2 證據: A-C 查詢容易 僅局部標示證據等級 院外連線加價昂($$$) 季 DynaMed 3,200疾病/藥物 Level: 1-3 Grade: A-C 查詢容易, 日更新 每頁首註明新近更新內容 (待考驗) 日 Clinical Evidence 470疾病: 3,000處置 @BestPractice 療效: 6級益害 證據: High Moderate Low 評論過程透明(Grade) 列出Clinical Questions 表格呈現療效 強調盡可能說明Harm 有提供excluded references 未提供etiology, diagnosis, cost 更新速度慢 採用英式英文 年 (月: 提供尚未review papers) First Consult 1,440疾病 提供test或therapy優先順序 非所有內容皆有實證 僅Tx標示EBM者 月 ACP PIER 651疾病 推薦: A-C 證據: 1-3 呈現推薦、理由、證據 主題數很少 (限同時2人上線) [註] UpToDate將同Medical Condition拆分為Diagnosis、Therapy等為一個Topic，故數量顯得相對多

31 Critically-Appraised Topics :給力要件
Update 定期更新，好歹好歹也一年一度 並註明更新內容與執行搜尋的最近日期 References 說明完整搜尋與取得最佳證據的過程 並註明原始出處 Evidences 透明呈現評判證據的準則，並據此嚴格評析文獻 憑證據陳述目前可能的最佳建議 更佳者指出證據與建議等級

32 學習單: 尋找證據

33 資訊檢索概念 單字 vs. “片語” 切截字 * 同義字 布林邏輯 檢索欄位 自由詞彙 vs. 控制詞彙 廣狹義詞

34 單字 vs. “片語” 疼痛處置 vs “疼痛處置” pain management vs “pain management”
在PubMed使用會關閉自動比對功能 宜用在非MeSH Term 疼痛處置 vs “疼痛處置” pain management vs “pain management” 華藝CEPS思博網 臺灣期刊論文索引 Google PubMed

35 單字 vs. “片語”

36 切截字* => therap* =>combin* therapy? therapy therapeutic
在PubMed使用會關閉自動比對功能 宜用在非MeSH Term therapy? therapy therapeutic therapeutics combine? combine combination => therap* 呼叫字典小天使 =>combin*

37 切截字* 在PubMed使用會關閉自動比對功能 宜用在非MeSH Term DPP 4 inhibitors AND metformin
DPP 4 inhibitors ＋ metformin DPP 4 inhibitors vs. metformin DPP 4 inhibitors AND metformin DPP 4 inhibitors AND metformin AND combin* DPP 4 inhibitors ＋ metformin

38 同義字 inhibitor inhibitors gastroesophageal reflux
用控制詞彙MeSH可避免大部分困擾 inhibitor inhibitors gastroesophageal reflux gastro-oesophageal reflux GERD lymph node removal lymphadenectomy lymph nodes excision lymph nodes dissection 淋巴摘除 淋巴切除 摘除淋巴 單複數 英美拼法 全名縮寫 同義異形字

39 布林邏輯 地瓜 營養 蕃薯 地瓜 營養 地瓜 蕃薯 種植 地瓜 營養 AND 地瓜 OR 蕃薯  地瓜 OR 蕃薯 AND 營養 

40 檢索欄位 篇名 Title 關鍵字 Keywords 摘要 Abstract
控制詞彙 MeSH Terms / CINAHL Headings 全文 Full Text 所有欄位 All Fields 影響檢索結果的相關性 !

41 檢索欄位: 哪一篇文章相關性高? (糖尿病)  

42 檢索欄位: 哪一篇文章相關性低? (roselle洛神花 )
  

43 articles translation database translation 自由詞彙 vs. 控制詞彙 queries
authors articles translation 系統控制使用者和作者用語一致 使用者要設法和作者心意相通 Gastroesophageal Reflux 控制詞彙派 Controlled Vocabulary 自由詞彙派 Free Text database Medline Standard Medical Subject Headings 較大型或精緻的書目資料庫 通常同時有這兩種機制 Gastroesophageal Reflux translation GERD 自由詞彙 vs. 控制詞彙 user queries

44 自由詞彙 vs. 控制詞彙 Free Text Controlled Vocabulary
例: 中文期刊論文資料庫、Google 檢索時系統比對原始文章的篇名、摘要作者等欄位 搜尋過程上較簡單 適用控制詞彙未提供的概念 新名詞: Severe Acute Respiratory Syndrome於2003始為MeSH 形容語: repeated fine-needle aspiration => repeat* 要儘可能列舉同義詞 => (intensive OR tight OR strict) AND glycemic control 語義容易模糊 => Roselle vs Roselle 可能要列舉狹義詞 例: Medline: MeSH、CINAHL Headings 檢索時系統將關鍵字比對控制詞彙表後做查詢 (文獻事前經索引程序) 解決同義字問題 可彈性檢索廣/狹義詞 可調整精確率與回收率 要”習慣”’才會用 新概念不適用 用語容易受限不彈性 原 理 優 點 缺 點

45 廣狹義字 廣義字 狹義字 All MeSH Categories
Analytical, Diagnostic and Therapeutic … Therapeutics Complementary Therapies Acupuncture Therapy Medicine, Traditional Sensory Art Therapies Art Therapy Dance Therapy Music Therapy Play Therapy Spiritual Therapies Meditation Mental Healing Yoga 廣義字 狹義字

46 PubMed :預設介面 限制 進階介面 個人化服務 輸入關鍵字、布林邏輯、檢索編號# 此PubMed網址和馬偕圖書館電子館藏有建立連結，可以把此網址加入我的最愛 醫學主題標題表 臨床最佳化篩選

47 PubMed :Advance (進階介面)
系統轉譯關鍵字細節 輸入關鍵字、布林邏輯、檢索編號# 指定欄位檢索 檢索歷史(保留8hr) 看此筆檢索結果 點#數字彈跳選項

48 PubMed :Details 控制詞彙 自由詞彙 系統如何自動轉譯使用者輸入的關鍵字:
關鍵字依序比對 MeSH表 刊名表  作者表等詞表 (先片語、再為單字比對) 若比對到MeSH: 以MeSH(含狹義詞,副標題)與All Fields檢索 若未比對到任何表: 關鍵字檢索All Fields 關鍵字加“雙引號”, 切截*, [限欄位] 就不啟動自動轉譯 PubMed :Details 系統的最終的檢索策略 系統的轉譯過程 控制詞彙 自由詞彙 使用者輸入關鍵字

49 PubMed :組成資料庫 1) MEDLINE
經Medical Subject Headings索引程序之資料庫，為PubMed主要組成部分 2) In Process 正在進行加工索引之書目，故尚無MeSH Terms 3) Publisher-Supplied 通常是出版社提供電子先於紙本發行之未正式出版文獻的書目，大部份會進入In Process，接著變成MEDLINE的一部份 4) PubMed Not Medline 僅佔少部份，為非MEDLINE收錄準則的文獻書目 5) NCBI Online Books NCBI收錄之850+本電子書及其章節索引

50 PICO P I C O 自然產 vaginal delivery 常規性使用會陰切開術 routine episiotomy
自然產期間常規使用會陰切開術對於新生兒出生結果並沒有好處? Is there no benfit on neonatal outcomes to routine use of episiotomy during vaginal delivery? P 自然產 vaginal delivery I 常規性使用會陰切開術 routine episiotomy C 限制性使用會陰切開術 restrictive episiotomy O 新生兒出生結果 neonatal outcomes (Apgar score, neonatal resuscitation, neonatal trauma) Type □ Diagnosis □ Therapy □ Prognosis □ Harm □ Etiology 

51 PubMed :Search (幼幼班) 太多 vs. 太少  太寬 vs. 太緊 episiotomy
vaginal delivery AND routine episiotomy AND restrictive episiotomy AND (neonatal outcomes OR Apgar score)

52 PubMed/Ovid Medline/CINAHL :搜尋策略
 使用 MeSH Term與列舉同義字  彈性組合 P I C O  限定欄位 [major] [mesh] [title] (調整相關性密技)  最佳化篩選 Clinical Queries  指定期刊 ACP J Club Cochrane Reviews…  限制條件 Limits  透過線索修正關鍵字 Filter your results

53 PICO 使用MeSH 與列舉同義字 P I C O
CEPS中英對照書目/ EBM Databases PICO 使用MeSH 與列舉同義字 自然產期間常規使用會陰切開術對於新生兒出生結果並沒有好處? Is there no benfit on neonatal outcomes to routine use of episiotomy during vaginal delivery? P vaginal delivery OR vaginal birth OR vagina* OR “normal delivery” OR “normal birth” OR Obstetric Delivery[mesh:noexp] OR Pregnancy I episiotomy AND routine* C episiotomy AND (restrict* OR selective*) O neonate OR neotat* OR newborn* OR fetal OR fetus OR Apgar Type vaginal delivery OR vaginal birth OR vagina* OR “normal delivery” OR “normal birth” OR Obstetric Delivery[mesh:noexp] OR Pregnancy episiotomy AND routine* episiotomy AND (restrict* OR selective*) neonate OR neotat* OR newborn* OR fetal OR fetus OR Apgar □ Diagnosis □ Therapy □ Prognosis □ Harm □ Etiology 

54   PubMed 使用MeSH 1) 避免使用縮寫 2) 檢查Details 3) 參考已知書目的MeSH Terms
ex. MRA  MRI  breast milk  PubMed 使用MeSH 1) 避免使用縮寫 3) 參考已知書目的MeSH Terms 4) 查詢MeSH Database確認用語 2) 檢查Details  

55 PubMed 使用MeSH 3) 參考已知書目的MeSH Terms ex. clowning (小丑療法增加試管嬰兒成功率)
a.輸入vaginal delivery[ti] 限定篇名以提高相關 b. Display Setting切為Format: Abstract 研究設計 c. 參考數篇相關書目 得知其MeSH Terms

56 學習單: 尋找證據

57 Demo: P PubMed 彈性組合 P I C O
vaginal delivery OR vaginal birth OR vagina* OR “normal delivery” OR “normal birth” OR Obstetric Delivery[mesh:noexp] OR Pregnancy

58 PubMed 彈性組合 P I C O episiotomy AND routine*

59 PubMed 彈性組合 P I C O episiotomy AND (restrict* OR selective*)

60 PubMed 彈性組合 P I C O neonate OR neonat* OR newborn* OR fetal OR fetus OR Apgar

61 PubMed 彈性組合 P I C O #3 AND #4 AND #5 AND #6

62 PubMed 彈性組合 P I C O P I P I C P I C O O C I P 一次檢索優點: 快速 (當對關鍵字有把握時)
episiotomy vaginal delivery AND routine episiotomy AND restrictive episiotomy AND (neonatal outcomes OR Apgar score) vaginal delivery OR vaginal birth OR vagina* OR “normal delivery” OR “normal birth” OR Obstetric Delivery[mesh:noexp] OR Pregnancy episiotomy AND routine* episiotomy AND (restrict* OR selective*) neonate OR neotat* OR newborn* OR fetal OR fetus OR Apgar #3 AND #4 AND #5 AND #6 #3 AND #4 AND #5 #3 AND #4 一次檢索優點: 快速 (當對關鍵字有把握時) 分次檢索優點 避免某面向檢索結果很低，影響整體結果 檢索結果低時，方便調整組合 PICO組合？取決問題特性、檢索者目的和時間、文獻需求質量

63 PubMed 限定欄位[major] [mesh] [title]
episiotomy/adverse effects[majr] OR episiotomy[ti] (調整相關性密技) 高 episiotomy/adverse effects[majr] OR episiotomy[ti] episiotomy[majr] OR episiotomy[ti] episiotomy[mesh] OR episiotomy[ti] episiotomy 低

64 PubMed 最佳化篩選Clinical Queries
#9 臨床面向  75 文獻量  16 Filter citations for systematic reviews, meta-analyses, reviews of clinical trials, evidence-based medicine, consensus development conferences, and guidelines. See related sources. Filter citations to a specific clinical study category and scope. These search filters were developed by Haynes RB et al.

65 Clinical Queries using Research Methodology Filters
Category Optimized For Sensitive Specific PubMed Equivalent therapy sensitive/ broad 99% 70% ((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading]) specific/ narrow 93% 97% (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract])) diagnosis sensitive/ broad 98% 74% (sensitiv*[Title/Abstract] OR sensitivity and specificity[MeSH Terms] OR diagnos*[Title/Abstract] OR diagnosis[MeSH:noexp] OR diagnostic * [MeSH:noexp] OR diagnosis,differential[MeSH:noexp] OR diagnosis[Subheading:noexp]) specific/ narrow  64% (specificity[Title/Abstract]) etiology 93% 63% (risk*[Title/Abstract] OR risk*[MeSH:noexp] OR risk *[MeSH:noexp] OR cohort studies[MeSH Terms] OR group*[Text Word])  51% 95% ((relative[Title/Abstract] AND risk*[Title/Abstract]) OR (relative risk[Text Word]) OR risks[Text Word] OR cohort studies[MeSH:noexp] OR (cohort[Title/Abstract] AND stud*[Title/Abstract])) prognosis 90% 80% (incidence[MeSH:noexp] OR mortality[MeSH Terms] OR follow up studies[MeSH:noexp] OR prognos*[Text Word] OR predict*[Text Word] OR course*[Text Word]) 52% 94% (prognos*[Title/Abstract] OR (first[Title/Abstract] AND episode[Title/Abstract]) OR cohort[Title/Abstract]) clinical prediction guides 96% 79% (predict*[tiab] OR predictive value of tests[mh] OR scor*[tiab] OR observ*[tiab] OR observer variation[mh]) 54% 99% (validation[tiab] OR validate[tiab])

66 PubMed :Filter your results
   

67 PubMed 指定期刊ACP, Cochrane
輸入關鍵字或#號碼 即自動將檢索策略帶入此區塊 按鈕Search/Preview #6 AND (“ACP journal club”[Journal] OR "Cochrane database of systematic reviews (Online)"[Journal]) 按鈕Add to… 輸入刊名關鍵字 ACP journal club acp... 指定欄位 選取AND 繼續以OR加入其他期刊直到完成

68 PubMed Limits 使用Limits後， In process 、supplied by publisher、非Medline 的文獻，將被排除～ 因為 Limits 條件大多是已加工索引完成書目才具有 破解: your keywords AND (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb]) #9   (區塊內OR；區塊間AND)  (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb])  勿與Type of Article併用

69 PubMed  透過線索修正關鍵詞 ex. (GERD & hoarseness) 文章乙: 篇名與摘要: 都未提到hoarseness
只有atypical manifestations 找到一篇文章甲：摘要中提到 hoarseness是GERD的atypical symptom 文章乙: 內文: 有提及hoarseness (關鍵字不一定會表現在篇名與摘要) Search GERD AND hoarseness = 255筆 Search GERD AND (hoarseness OR atypical)= 619筆

70 PubMed :Search Strategy (中班)
Most Recent Queries Result #15 #9 Limits: Humans, Meta-Analysis, Randomized Controlled Trial, English, Chinese, Core clinical journals 7 #14 Therapy/Narrow[filter] AND #9 16 #13 Therapy/Broad[filter] AND #9 75 #12 systematic[sb] AND #9 24 #11 episiotomy[majr] OR episiotomy[ti] 995 #10 episiotomy[mesh] OR episiotomy[ti] 1585 #9 #3 AND #4 #8 #3 AND #4 AND #5 41 #7 #3 AND #4 AND #5 AND #6 #6 neonate OR neotat* OR newborn* OR fetal OR fetus OR Apgar 822031 #5 episiotomy AND (restrict* OR selective*) 127 #4 episiotomy AND routine* 183 #3 vaginal delivery OR vaginal birth OR vagina* OR “normal delivery” OR “normal birth” OR Obstetric Delivery[mesh:noexp] OR Pregnancy 788585 #2 vaginal delivery AND routine episiotomy AND restrictive episiotomy AND (neonatal outcomes OR Apgar score) 2 #1 episiotomy 2152  Limits  Clinical Queries Filters  調整相關性密技  彈性組合PICO  使用MeSH, 同義字 O C episiotomy vaginal delivery AND routine episiotomy AND restrictive episiotomy AND (neonatal outcomes OR Apgar score) vaginal delivery OR vaginal birth OR vagina* OR “normal delivery” OR “normal birth” OR Obstetric Delivery[mesh:noexp] OR Pregnancy episiotomy AND routine* episiotomy AND (restrict* OR selective*) neonate OR neotat* OR newborn* OR fetal OR fetus OR Apgar #3 AND #4 AND #5 AND #6 #3 AND #4 AND #5 #3 AND #4 episiotomy/adverse effects[majr] OR episiotomy[ti] episiotomy[majr] OR episiotomy[ti] episiotomy[mesh] OR episiotomy[ti] I P 幼幼PICO(快速法)

71 學習單: 尋找證據

72 Ovid Medline :Limits about Clinical Queries:

73 CINAHL :Limits

74 Cochrane Library  Cochrane Database of Systematic Reviews
 Database of Abstracts of Reviews of Effects (Other Reviews) NHS精選Systematic Reviews，部份提供結構化摘要 原始文獻可能被MEDLINE索引  Cochrane Central Register of Controlled Trials (Clinical Trials) 檢索自Medline(3/5)、EMBASE，人工搜尋2,400+種專業期刊  Cochrane Methodology Register  Health Technology Assessment Database -- NHS Economic Evaluation Database -- About The Cochrane Collaboration : PubMed收錄該出版品  : 可能與PubMed部份重複收錄

75 Cochrane Library :Search
vaginal delivery OR vaginal birth OR vagina* … episiotomy AND routine* episiotomy AND (restrict* OR selective*) neonate OR neotat* OR newborn* OR fetal…

76 PubMed :MyNCBI :Filters http://library. mmh. org
PubMed :MyNCBI :Filters (p.14,16-17) 嘛ㄟ通!

77 PubMed :MyNCBI :Filters

78 PubMed :MyNCBI :Filters

79 EBM Filtered Resour 語法 Save filter as (命名) Query Terms (查詢語法)
BMJ Clinical Evidence "clinical evidence"[Journal] ACP J Club + EBM J “ACP journal club”[Journal] OR “evidence based cardiovascular medicine”[Journal] OR “evidence based complementary and alternative medicine ecam”[Journal] OR “evidence based dentistry”[Journal] OR “evidence based medicine”[Journal] OR “evidence based mental health”[Journal] OR “evidence based nursing”[Journal] (共6本實證評論期刊) Systematic Reviews systematic[sb] --- Cochrane Syst Rev "cochrane database of systematic reviews online"[Journal]

80 EBM Unfiltered Resour 語法
Save filter as (命名) Query Terms (查詢語法) Therapy‧RCTs Therapy/Narrow[Filter] Therapy‧Clinical Trials Therapy/Broad[Filter] Diagnosis/Broad Diagnosis/Narrow[Filter] Prognosis /Broad Prognosis/Broad[Filter] Etiology /Broad Etiology/Broad[Filter] Qualitative /Broad interview*[tiab] OR psychology[sh:noexp] OR health services administration[mesh] 更多篩選機制(包括Costs, Economics, Clinical Prediction Guides) 參考:

81 PubMed :Filter your Results
整型前 v.s. 整型後 節省至少1分鐘的耐心! 增加更多證據信心! 1分鐘有 多重要!?

82 PubMed :MyNCBI :Filters (分享設定)
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83 PubMed :MyNCBI :Filters (分享設定)
MyNCBI設定分享 (URL公開網頁 或 加入我的最愛) (個人範例) (機構範例) 觀摩測試用 (開放至12/31) 帳號: mmhdemo 密碼: mmhdemo

84 我們的宗旨 協助醫療從業人員 快速有效取得現有的最佳實證 Quick。Effective。Current。Best 