clinical scenario. step 1: ask an answerable clinical question--p. i. c. o. patient / problem :...
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Clinical Scenario
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Step 1: Ask an answerable clinical question--P. I. C. O.
Patient / Problem : Intervention / Exposure:
Comparison: Outcome:
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PICO
Question:
• Patient / Problem : • Intervention / Exposure: • Comparison: • Outcome:
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Step 2: Effective searches for the best Evidence
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搜尋策略的設計表 SEARCH STRATEGY DESIGN TABLE
主要詞彙 Primary Term
同義字 Synonym 1 同義字 Synonym 2
P OR OR AND
I OR OR AND
C OR OR AND
O OR OR AND
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實際搜尋 ACTUAL SEARCHES
Cochrane 搜尋
文獻數
PubMed 搜尋 文獻數
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Step 3: Critically appraise that evidence for its validity and
importance
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A. 此一有害原因的研究的結果能令人信服嗎 ?Are the results of this harm study
valid?
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1. 實驗組與對照組除了對治療的曝露有別外 , 其他方面是否皆相似 ?
Were there clearly defined groups of patients, similar in all important ways other than exposure to the treatment or
other cause?本文獻: □ Yes □No □Unclear
評論 Comment :
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2. 實驗組與對照組的評量方法是否相同 ? Were treatments/ exposures and clinical outcomes measured in the same ways in both groups (was the assessment of outcomes either
objective or blinded to exposure)?
本文獻: □ Yes □No □Unclear
評論 Comment :
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3. 追蹤夠久夠完整嗎 ? Was the follows-up of study patients complete
and long enough?本文獻: □ Yes □No □Unclear
評論 Comment :
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4. 因果關係夠明確嗎 ? Do the results satisfy some “diagnostic tests for
causation”?a) 曝露在發作之前嗎 ?
Is it clear that the exposure preceded the onset of the outcome?
b) 與劑量具有相關斜度嗎 ?
Is there a dose-response gradient?
c) 從”去曝露 -- 再曝露”的研究上有正面證據嗎 ?
Is there positive evidence from a “dechallenge-rechallenge” study?
d) 因果關係具有生物學上的意義嗎 ?
Does the association make biological sense (in terms of pathophysiology, etc.)?
本文獻: □ Yes □No □Unclear
評論 Comment :
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B. 此一有害原因的研究的結果夠重要嗎 ? Are the valid results from this harm
study important?
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5. What is the magnitude of the association between the exposure and outcome?
• In a randomized trial or cohort study: relative risk (RR) = [a/(a + b)]/[c/(c + d)]. NNH = 1/ [a/(a + b) − c/(c + d)] = 1 /│1-RR│x PEER • In a case-control study: relative odds (OR) = ad/bc (RR can’t be calculated because the investigator selects the people with the outcomes (rather than those with the exposure) and we can’t calculate the “incidence”) • if OR <1: NNH = if OR >1: NNH = where PEER is the patient expected event rate (the adverse event rate among individuals who are not exposed to the putative cause).
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6. What is the precision of the estimate of the association between the exposure and
the outcome? (CI: confidence interval)• We might not want to label an OR from
a case–control study as impressive unless it is >4 for minor adverse events, and we’d set this value at progressively lower levels as the severity of the adverse event increases.
• There is less potential bias in cohort studies and therefore we might regard a relative risk of >3 as convincing for more severe adverse events)
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C. 此一令人信服且結果重要的研究的會改變我們對病患的治療嗎 ?
Should these valid, potentially important results change the treatment
of our patient?
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7. 我們的病患與研究中收錄的病患有明顯不同 ? Is our patient so different from those included in
the study that its results don’t apply?本文獻: □ Yes □No □Unclear
評論 Comment :
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8. 此項治療對我們的病患潛在的危害為何 ? 潛在的益處的為何 ?
What is our patient’s risk of the adverse event? What is our patient’s potential benefit from the therapy?
本文獻: □ Yes □No □Unclear
評論 Comment :
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9. 病人對治療的喜惡與期望為何 ?What are our patient’s preferences, condemns and
expectations from this treatment?
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10. 有其他治療方法嗎 ? What alternative treatments are available?