臨床場景(Clinical Scenario)

Presentation on theme: "臨床場景(Clinical Scenario)"— Presentation transcript:

1 臨床場景(Clinical Scenario)
問題 Ask 臨床場景(Clinical Scenario) 60 y/o女性農婦，20歲結婚後就跟著先生經營農場，主要種植柑橘和玉米。平時身體狀況不錯，只是血中尿酸自30歲起就發現一直在9.0以上，因為沒有症狀所以一直不管它。10年前開始左大腳趾關節腫痛過幾次，每次吃個3天普拿疼後都會好。5年前開始兩個膝蓋開始有酸痛現象，因此就不再從事搬運農作物的工作，但仍然每天去巡視農場。最近因右膝疼痛越來越厲害，影響走路而去看醫生，被診斷為退化性關節炎(osteoarthritis)。在美國工作的親戚寄了”維骨力” (glucosamine)給她，她來醫院請教是否可吃，有沒有效? 會不會影響尿酸？

2 Patient’s concern 問題 Ask
維骨力 (glucosamine)對於退化性關節炎(osteoarthritis)有沒有疼痛緩解的效果? 維骨力 (glucosamine)會不會影響尿酸值?

3 ■介入型 □病因型 □診斷型 □預後型 □頻率型 □現象型
問題 Ask 臨床問題(PICO-I) P (Patient/Problem) Patients with knee osteoarthritis I (Intervention) Glucosamine C (Comparison) Placebo O (Outcomes) Pain management Type ■介入型 □病因型 □診斷型 □預後型 □頻率型 □現象型

4 ■介入型 □病因型 □診斷型 □預後型 □頻率型 □現象型
問題 Ask 臨床問題(PICO-II) P (Patient/Problem) Patients with knee osteoarthritis I (Intervention) Glucosamine C (Comparison) Placebo O (Outcomes) Adverse effects (uric acid...etc.) Type ■介入型 □病因型 □診斷型 □預後型 □頻率型 □現象型

5 檢索 Aquire 搜尋策略 我們的「搜尋資源」包括：

6 搜尋策略,關鍵字 檢索 Aquire P Patients with osteoarthritis Osteoarthritis I
Key words Osteoarthritis I Glucosamine C Placebo nil O Pain management

7 搜尋歷程 Syntheses 檢索 Aquire Question type Study design Diagnostic test
診斷性檢驗或檢查 Prospective, blinded cross-sectional study comparing with gold standard 前瞻性、盲法、與黃金標準進行比較之斷面研究 Prognosis 預後 Cohort study > Case control study > Caseseries study 世代研究> 病例對照研究> 病例系列研究 Etiology 病因 Therapy 治療 Systematic review of randomized control trials> Randomised control trial (RCT) Prevention 預防 Randomised control trial (RCT) 隨機對照試驗 Cost effectiveness 成本效益 Economic analysis 經濟分析

8 檢索 Aquire 搜尋結果 標題 摘要內文 資料庫 找到文章數量 符合PICO的文章數量 1 24 2 22 3 12

9 文章選定 檢索 Aquire Level of evidence: 1 Systemic review of RCTs 符合臨床問題
研究設計適當 有全文 Level of evidence: 1 Systemic review of RCTs (Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence)

10 文章選定 檢索 Aquire  Yes 本篇研究內容 我們設計的PICO P I C O
Patients with osteoarthritis  Yes I Glucosamine C Placebo/NSAID O Pain relief/Functional preservation/Toxicity

11 嚴格評讀 評讀 Appraise  Validity  Importance  Practice
Critical Appraisal Skills Program (CASP) 本篇系統回顧是否提出明確定義的問題? 選擇收錄研究的標準是否適當? 本篇回顧的搜尋策略是否可能有遺漏合適的臨床試驗? 其所收錄的研究是否有效力的研究? 若為meta-analysis，所收錄的研究是否有足夠的一致性可以合併研究資料? 研究結果呈現的適當性?

12 文獻評讀 評讀 Appraise CASP- Systematic review 本篇系統回顧是否提出明確定義的問題?  Yes
To assess the effectiveness and toxicity of glucosamine in the pharmacological management of OA. Both symptomatic effectiveness and structural effectiveness (that is, delay in radiological progression of OA) were evaluated.

13 嚴格評讀 評讀 Appraise Validity CASP- Systematic review 選擇收錄研究的標準是否適當?  Yes
The first criteria were used to screen all citations that involved glucosamine in the management of OA. The second criteria were used to identify those studies that met the following additional requirements: 1) RCTs evaluating the efficacy and toxicity of glucosamine in OA, 2) both placebo-based and comparative studies were eligible, 3) both single-blinded and double-blinded trials were eligible, 4) studies to be included in the quantitative portion of the review (meta-analysis) must have presented suitable quantitative data for pooling across trials, 5) studies that enrolled participants with OA at any body site were eligible with the only exception being studies that evaluated glucosamine in temporomandibular joint (TMJ) disorders, 6) only studies which evaluated glucosamine-only preparations were included (studies which evaluated combination products containing glucosamine in association with other active compounds, for example chondroitin, were excluded), 7) glucosamine could have been administered by any route.

14 嚴格評讀 評讀 Appraise Validity CASP- Systematic review
本篇回顧的搜尋策略是否可能有遺漏合適的臨床試驗?  Yes A MEDLINE search (1966 to November 1999) was used to identify all relevant RCTs for the first version of this Cochrane Review. For the second version of the Cochrane Review, all searches were updated (in January 2005). The same MEDLINE search strategy was extended for this updated version of the review (up to week 1, January 2008). MEDLINE In-Process and other non-indexed citations were also searched (January 2008); MEDLINE Daily Update was searched (January 2008). In addition, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library), AmericanCollege of Physicians (ACP) JournalClub, andDatabase of Abstracts of Reviews of Effectiveness (DARE) were searched (up to January 2008); Allied and Complementary Medicine (AMED) was searched (1985 to January 2008); and EMBASE was searched (1980 to week 2, January 2008

15 嚴格評讀 評讀 Appraise Validity CASP- Systematic review
其所收錄的研究是否具有效力(quality)?  Yes Two review authors (TT and TP or LM) used the screening criteria to review all identified citations independently. All citations identified by either investigator were retrieved and analyzed for suitability. Authors of abstracts were contacted requesting the full manuscript, including the raw and final data incorporating the results.

16 嚴格評讀 評讀 Appraise Importance CASP- Systematic review 結果呈現是否適當?主要的結果是什麼?
 Yes

17 嚴格評讀 評讀 Appraise Importance CASP- Systematic review 結果呈現是否適當?主要的結果是什麼?
 Yes I2 low: <=0.2; middle: ; high: >0.5

18 嚴格評讀 評讀 Appraise Importance CASP- Systematic review 結果呈現是否適當?主要的結果是什麼?
 Yes I2 low: <=0.2; middle: ; high: >0.5

19 嚴格評讀 評讀 Appraise Practice NNT;number needed to treat RR ARR RRR NNT
1.52 [ 1.20, 1.91 ] 17.5% 26.6% 6人 試驗終點是否為重要的臨床預後?  Yes

20 臨床應用 應用 Apply 100位病人使用葡萄糖胺有17位病人的疼痛指標Lequesne Index獲得改善(NNT=6) A B
10 × 10 100位病人使用葡萄糖胺有17位病人的疼痛指標Lequesne Index獲得改善(NNT=6) A B

21 臨床應用 應用 Apply http://www.nhi.gov.tw/
I2異質程度: I2=(Q-df)/Q x 100% (df=study numbmer -1) low: <=0.2; middle: ; high: >0.5 Cochran Q(Q-TEST) Q/df>1=>possible heterogeneity. Q/df<1,p=0.5=>no heterogeneity.

22 Evidence Systemic review of RCTs 35 35