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1、循证医学研究证据的来源与检索,张啸飞浙医二院 临床流行病和生物统计中心,复习： 什么是循证医学？ Evidence-based Medicine？,2017/12/23,2,Evidence-based medicine (EBM),Evidence-based medicine (EBM) is the name given to the the conscientious, judicious and explicit use of current best evidence in making decisions about the care of the individual pati
2、ent (Sackett et al. BMJ 1996).,EBM，循证医学（Evidence based Medicine）： 是临床医生经过认真尽责地、正确判断地且很明确地做出决定：将最佳证据应用于临床实践诊治病人以便于取得最佳诊疗效果。,2017/12/23,4,EBM,The thinking behind evidence-based medicine is very soundly based on Clinical Epidemiology; and the practice will be familiar to those of you who have experienc
3、e of problem-based learning.,EBM,The philosophy of evidence-based medicine is not new. What is new is the enormous and growing capacity to access knowledge in an efficient manner. Evidence-based medicine exploits the information explosion that might otherwise overwhelm us. The skills being to ask th
4、e right questions, look for answers, and interpret and apply those answers for the best health outcomes.,EBM,Evidence-based medicine is a tool with many applications:to complement clinical expertise in providing best care for patients;to make best, rational, use of limited resources;as an aid to con
5、tinuing education and professional development.,EBM,四大因素的有机结合,2017/12/23,9,临床流行病学方法学基础,最佳研究成果,素质良好医师,患者的参与,循证医学,STEPS IN EBM,Evidence-based Medicine starts with a well-defined clinical problem and then seeks best evidence to solve this problem for the individual patients situation. There are four ma
6、in steps:,STEPS IN EBM,Framing Clinical Questions.Searching for Evidence.Appraising the Evidence.Applying the Evidence.,复习： 怎么构架问题？或者都有哪些问题需要来回答的？,2017/12/23,12,Step 1 - Framing Clinical Questions,询证医学的第一步是问正确的临床问题：这些有关患者保健问题都是医生每天所要面对的。如何解释这些临床结果?哪些诊断试验有助于诊断和管理病人?哪些治疗将会带来最大的“风险与获益”比?预后是怎样的?,Step 1
7、- Framing Clinical Questions,Eight central tasks of clinical work that generate clinical questions:临床结果（Clinical findings）: 怎样恰当地采集病史，并根据病史和身体检查来解释临床结果 。（how to properly gather and interpret findings from the history and physical examination.）病因学（Etiology）: 怎样来识别或鉴定病因 （how to identify causes for dis
8、ease (including its iatrogenic forms， 医源性的)）？,Eight central tasks of clinical work that generate clinical questions:,Differential diagnosis （鉴别诊断）: when considering the possible causes of a patients clinical problem, how to rank them by likelihood, seriousness and treatability.Diagnostic test （诊断检查）
9、: how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosis, based on considering their precision, accuracy, acceptability, expense, safety etc.,Eight central tasks of clinical work that generate clinical questions:,Prognosis （预后）: how to estimate the patients likely c
10、linical course over time and anticipate likely complications of the disease.Therapy （治疗）: how to select treatments to offer the patients that do more good than harm and that are worth the efforts and costs of using them.,Eight central tasks of clinical work that generate clinical questions:,7. Preve
11、ntion （预防）: how to reduce the chance of disease by identifying and modifying risk factors and how to diagnose disease early by screening.8. Self-improvement （自我完善）: how to keep up-to-date, improve you clinical skills and run a better, more efficient clinical practice.,Step 2 - Searching for Evidence
12、,Having framed your question, the next step is to identify sources of information. These might include:TextbooksJournals and Newsletters. For example:American College of Physicians Journal Club Evidence-based Medicine Scientific reports/ Government reports. For example:National Health and Medical Re
13、search Council Health Advisory Committee,Step 2 - Searching for Evidence,Guidelines. For example:The United States Preventive Services Task Force - Guide to Clinical Preventive Services EMJA Clinical Guidelines Databases. For example:Cochrane Library Best EvidenceBibliographic databases. For example
14、:Medline EMBASEOther internet sources. For example:DARE,2017/12/23,20,2017/12/23,2017/12/23,22,2017/12/23,23,2017/12/23,24,2017/12/23,25,2017/12/23,26,循证医学实践的步骤,检索相关文献 根据提出的临床问题，确定“检索词”利用各种权威的检索系统检索相关文献。从检索结果中找出与问题关系密切的资料，作为分析评价之用。文献检索只是循证医学实践中的一个环节。,2017/12/23,27,寻找外部证据的途径,教科书与专著：从教科书与专著循证是传统的方法，但不
15、是最佳的方法。因为许多临床的问题，难以从教科书中找到令人满意的解答。各个层次的教科书一般来说已经成熟的理论多体现在教科书，专著也多是每数年再版一次，除成熟的理论外，多有作者比较成熟的经验和观点。对于全科医生和低年资的专科医生，教科书和专著往往是循证的重要途径。即使是高年资的专科医生，也常常需要浏览教科书和专著，以较全面地了解本学科的总体发展。对于特殊临床问题的循证，往往需要从后面几个角度去寻找外部的证据。,2017/12/23,28,医学期刊是循证医学最重要的源泉,国内外际上有数以万计的医学期刊。循证医学，需要学会快速地检索和获取医学期刊文献。通过互联网络检索是最快获取资料的方法之一，有许多检
16、索方法和网址，其中较常用的之一是美国国家生物学技术信息中心的PubMed网页从互联网络上所能获得的文献的原文是很有限的，图书馆中的期刊是循证医学的源泉。在获得所需要的文章以后，还要运用临床流行病学的方法判断该研究的可靠性和有效性。,2017/12/23,29,一次文献：专著，期刊论文，科技报告，学位论文。 二次文献：索引，文摘，目录，相应的数据库。 三次文献：综述，评述，进展，现状，发展趋势等期刊文献和百科全书，年鉴，手册等参考工具书。 零次文献：实验数据，观测记录，调查材料。,2017/12/23,30,2017/12/23,31,2017/12/23,32,PubMed：美国国立医学图书馆创建，收集全球70多个国家和地区3900余种杂志，Evidence-Based Medicine是主题词（MeSH Term） http:/ncbi.nlm.nih.gve/PubMed Cochrane Library：每年四期，http:/中文生物医学文献数据库（CBM）：中国医学科学院医学信息研究所研制,
