1、第十屆實證醫學文獻查證類競賽組別: 進階組參賽編號: AC00061三軍總醫院陳成桃、葉爵榮、楊翔宇臨床情境 一位45歲的科技業研發工程師，工作時間很長，長期失眠且疏於運動。身高172公皆、體重78公斤（BMI約26），在最瑄一次公司所安排的例行性體檢中發現：血中膽固醇值為280mg/dl、三酸甘油脂348mg/dl、LDL（低密度脂蛋白膽固醇）160mg/dl、HDL（高密度脂蛋白膽固醇）30mg/dl，其他檢查結果無特殊發現。 這位工程師主訴：家人都屬肥胖體質，父親有冠狀動脈心臟病，在65歲時植入心臟血管支架，目前規則服藥控制中。母親有高血壓、中風及糖尿病。自已因為晚上睡不著，近兩年來斷續

2、使用藥物治療：睡眠障礙（Stilnox 10mg HS）與高脂血癥（Lipitor 10mg QD）。過去曾因腎結石採用ESWL治療兩次。 本身沒有飲酒習慣，但壓力大時，臨床情境沒有飲酒，每週約2包。學生時代有運動習慣(每週跑操場約5公里) ，開始工作後，有空會以Wii健身，一次約30分鐘。最近半年每天平均工作時間超過14小時，每天約喝500cc黑咖啡提神，吃完宵夜，回家倒頭就睡。What are the patients concern?1 看到新聞報導指出，青壯年發生中風及心肌梗塞比例逐年增高，又常感到頸部僵硬，很擔心現在生活習性對疾病的影響?2 家族疾病遺傳的可能性?3藥物的選擇是否最好

3、?藥物的副作用?藥物會不會造成結石?4胸悶心悸的病因?5 疾病的癒後?6高血壓、中風及糖尿病能不能預防?7 希望可藉由自然的方式(如:改變生活型態或運動) 、來降低心肌梗塞的機會。8最近他在廣告上看到關於每天食用麥片取代一餐，可以有效降低膽固醇、預防心臟病的報導，想知道是否屬實在執行，或者還有其它方式可能改善它目前的問題Five Steps of EBM1Asking answerable Clinical Question?2Tracking down the best Evidence3Critically Appraise Evidence4Apply to your patient5E

4、valuation your performance 一位45歲的科技業研發工程師，工作時間很長，長期失眠且疏於運動。身高172公皆、體重78公斤（BMI約26），在最瑄一次公司所安排的例行性體檢中發現：血中膽固醇值為280mg/dl、三酸甘油脂348mg/dl、LDL（低密度脂蛋白膽固醇）160mg/dl、HDL（高密度脂蛋白膽固醇）30mg/dl，其他檢查結果無特殊發現。希望可藉由自然的方式(如:改變生活型態或運動) 、來降低心肌梗塞的機會。Step 1. Asking answerable Clinical Question?PatientA 45-year-old man with H

5、yperlipidemia and have CAD high risk and R/O Metabolic syndromeInterventionDrugs therapyComparisonLife style controlOutcomePrevention AMI or CAD formation rate, MortalityPatientA 45-year-old man with Hyperlipidemia and have CAD high risk and R/O Metabolic syndromeInterventionAtrovastatin (Lipitor )C

6、omparisonOther drugs OutcomePrevention AMI or CAD formation rate, MortalityPICO type :TherapyKeywordPA 45-year-old man with Hyperlipidemia and have CAD high risk and R/O Metabolic syndromeMale, Hyperlipidemia,Metabolic syndrome,IDrugs therapyAtrovastatin , statin, HMG-COA reductase inhibitorCLife st

7、yle controlPlacebo, diet , sports, exerciseOPrvention AMI or CAD formation rate, MortalityMortality, Treatment effect,Effectiveness, Cost-effectivenessStep 2. Tracking down the best EvidenceSearch DatabasesStudiesSynthesesPrimary databaseSecondary databaseSynopsesSummariesSystemsSearch DatabasesHype

8、rlipidemia treatmentHyperlipidemia treatmentHyperlipidemia treatment資料庫 搜尋到的篇數符和PICO篇數證據等級202SR772SR 0 0SR 182SR402SRSearching databaseDetermining Question Type ?1Therapy2Harm/Etiology3Diagnosis4Prognosis Step 3. Critical appraisal EvidenceIs the systematic review validAre the result Important?Can t

9、he results help me?Appraising systematic reviews1Is this a systematic review of randomizedtrials?* Results of previous randomised trials have shown that interventions that lower LDL.*14 trial, Randomized, double-blind, placebo controlled, with concealed allocation.*Level: 1aYes2Does the methods sect

10、ion adequately describe:(a) finding and including all relevant trials?(b) assessing their individual validity?*A protocol for the Cholesterol Treatment Trialists (CTT) Collaboration was agreed in November, 1994, before the results of any of the relevant trials became available, and was published the

11、 next year.*Two reviewers (CGB, JoW) independently estimated the quality of the included studies. The Cochrane approach to assessing adequacy of allocation concealment was used (Jadad 1996; Mulrow & Oxman 1997) Study designYes3Are the studies consistent, both clinically andstatistically?*The gro

12、ups of patients, interventions and outcome measures were similar enough to merit combining their results.* Heterogeneity: No significantYes4Were the individual patient data used in the analysis (or aggregate data)?*SubgroupYesAre the Valid results of this systematic review important? *Measure of eff

13、icacy: OR, RR *Measure the benefits and harm of the therapy: NNT, NNH *Precise are these results: 95% CIYesTreatment Better Control betterTreatment Better Control betterTreatment Better Control betterTreatment Better Control betterCan you apply this valid, important evidence from a systematic review

14、 in caring for your patient?1. Is your patient so different from those in the study that its results cannot apply?No2. Treatment feasible in your patient in your setting?Yes3. What are our patient potential benefits and harm from the therapy? (NNT, NNH)Yes4. Are our patients values and preferences s

15、atisfied by the regimen and its Consequences?Yes不同臨床決策對醫療品質的影響傳統方法EBM 方法過程藉由前輩的教授及教科書的內容來獲得答案。經由一套有系統的文獻檢索、評估與評論過程來獲得臨床問題答案。對疾病的治療多數專家意見常有相異之處，缺乏具體的證據說服他人，因此也難以形成治療的共識。當有清楚的證據支持某項治療時，就容易形成Guideline，也可以使疾病的治療更有效率。給病患貼心的建議gobqMUrbY7Leu1Pc8hhXMz-XSwH&7YYVtrscsT-RSPmhf&5py8+Wh0UlgkaCaLVhO#v8HGT#

16、EDCef37L1As0KGbKqHM#zYg(lG8d6aJ#bU4lUWOOe*H&FjNCBoNiR#mT(EjWJreungvg%VdrMqTdDf-BET!EBx549BfQrwj9ma%-G34nDtI!cGbe+Z5)XzUfxhhcP&3wvmr*kR%rZ2IlQRFB#&x66d4uC88YGM5vFc(FPiYSmJ!Fva6G92HoEg1LLh%*JaeNkUXLFFHJr(NI2f$eV7W8oOT2eEBAKQ$YhJboM)&gXLuf#t*A2y-jFQ2K9*#wvJhz%U1le4VW2EGQLUsmiJ#1)4tHSfXM

17、m(8f7n%R$5)(VFkD7+Dlt&-#vKM0dylsqN8SPGwU$wEfLESQNg93VR$7rPD+1kDUhd%Ox-&j7!FvSisNbhWkxjn*dDAP6306tbOyp25Oh7p-svHX7*hyY(Pd*AXob!mC4z+q0EBDXEBDvnAH&8Fez(Nf*#(Vxw3ib*KMl2BITudIUWcv(!MFzF5b&kwA5ueKhRHlP&-cVMG+TPRv&SQh$0JsAZ9T4E&Lk+T5KKhj+(bv!6hnN$niEWIq&Orr&DsLAKxo)mg0

18、hR981UKfWlx5uIwb#VKL)0#Wsng(G2V19pHpyy&$TYxW2xhV2XJ#5ToGvE67t%FOkDAUqpGa*3DDcpuPS$Hb-BLq(XcS9wsxCn7%6d-8uH768115$kZEQJ$GIOBLi0fdj#VSvEKF-bu4rNj3+R0yZY9uuWmHrqhOxfKxq3gFVHNRyFSO7N89sI+Rws!fPK8qjAVXfHbd-YryIxRo8q3*vit#&ZxYuFz7RXmHgqa6J3hOFCg1X6*wqY)psy30+P*NxjlP6Y#qban*y!5OKULyz)huTVve0stRbBZF

19、Ne)2LIO41Jdm$iX5UotE*TPcbyy9i)qt%kgcQMXq*ZxPX&5DWt0LVfzMyJdM0rppLm94OT7#GNUFsZIs*G#WiA7-I3$XJo-(I(djHwdV$frLkg#weV&ojXD!921&zEJ05NNLFQxrOze*nU7XWe6P%OMHYV12&iOFnOScMBU$9NkX2HfG23fYfKuZiGqk3o#ntXjw3TmqLZMV(Wu3Zbjx4pKe0$FS97i80evOSkB*UqyD-1S194rD1YaR5JND!wBqG87s%FPjDCJlgPcSKOIBA-dm(&am

20、p;4N4JnV!0bLZTX4mjTRPEJbJ(MMGQy-41+zP-I685#+*Cc8cbA3Pg&r1vu+BISF&0fGaOdFe4KR2iz4o$1flU+3dZ38$8tjo(9AGZ-lJB!-N7Vo3)5vlO7CcPlZ8i&9ECEj)D+C%MGH1rk!+!cG72MmkZovfc0t7S6VF89lo(NZqBJ)#HzYBq#PGkg1+uYF*JaOXJwUbMGjOX9yvtFYbjhFA85-nLTm&H4$!MZ0#&jBjAy0ZIlwVi0#1zVOlp!d2L8m5mOwtlIwPz90kGEYsndK

21、pslbv+ivz8lvgLAZ+n-l2AvRm1!hdPb4r(WEw%v-2kxIFWcSUcZOr7KQvk9l)3QkxhgoX1eWRTG&0GFi)G8Jrl7zbW9XG9anr0!Qh7xTJodyBYskh&vc3t*Sf0M8atoV1uhUo$e2KQtj8h7ewOEBpup(MwlSOHBF+q*IZZHi(o3-efqgEvqi6wmfba3Yr!FY3nhE+jgNEg(aN9GRs$)gql-8JxmXV5QnDfZ#q8jaCYNhp7W07$qsqwwt#8AP&$*c87Xxc3rANh1VmilcEcNWiP#v7GERXAyw

22、rnchWeSYeD%A1Tun73uYZya%0AtI!fFiB2nsdPtxeZ0JIEcEu-CFctDE2ycf(BzNM1uEe!rGrjJzC#z-%tgSXHa)!p&yxOP#PuCHQ!zUTEP5ALZNTbljxnvCaxPbZ!wHYI!5NNvqqTj!66fRBjOCv9lK!NTXDLXTcRddvLCUur!gQT5me4VUnO96f6oelp7R*M!1%O+-$EP6Ks8yLYlLa-A#9p!c8xN#ksmfh&z7zoIgmo-l1LZ1$-%rgx8eowEe+u1H*zagwxwPvPbFg*P6BYsF29*m2(7ZzRgR

23、Gw5xorbM&eW5iNLxtW(aM#0soa7BO*&Ku&ZFNjItH8ZG&m%2a%sDU&VbbzXFE%d-i+GX$xRPVao3k#oz3IOGO02+6&EK3E879U7UQ*tUZzYpBR-ypHPDp7csA7YPeIPd&oe6t+#Pbfl7sGhmrDsH$A-lRJi&Fny7#yJ366SqhN-wrrIyMHLkV)VZM5cdWKADp1%RcKN9-49wyu&V9iftnP4)phve32$)-wm%xR2qIeTKrnjuVL4Z0C6aJ#%V!cc(V$CKoP%z

24、e2Ie79&1SanxI$FB7q0Phka9EP$uFMzIGwSV$ovyUJoh&YNnzJ2vGFtM1PnDe0!&Pay6YZWoFX%zoPye#rf&64I4y(haAxHwF&c4m$%zBiSYly3P1qJjOW4e8j06Rh(qt6AIVu+Y#7Uq$s$Nt7GGTH*-6wvow6D99ZHNs2%m$BPbE#v)Qth*nYu7BBnSCpfH%KrpqNnP!OR7ndz4ghPx6bXaDnZ9n-EiatMWTDHqQW!t&93y-XdjY*!j%NgB-I*fm4QSfKfi4Dkpwi(HvRY2

25、H#8LVX4Um*)OvynS+O!6Q41o2Oa9AFkr*x9c+c-Lt58*HZIN7ey*Koj6QN)zBe)e%*SIm&+9l%LVlL&TMCySzDQLo(G9*up$0ekZiPR3af*GzEkY)nKH&jq%G8cxNDRBFdNp(22K%)lhv4DXhyy(RrrZJKCI!%fgpjXeYV)ia1XAF9-lKt9%4c+J(TfNSlKJ0hIzqL#al!cC1&$hebHBncNs1fOd)pLonAFgc6ONSHE4NRBn-ezDuRepP1AdKTbvFNwbgAMXmFnm-H92BaEE5UUzDL5Z

26、TM2Va(yQ0BePDKBcMlDg$Wldo5x$QfpuS%f5pr2ICBg3RG$)6GR#if33BT6Lj%j3E#KfFBTxAmUwNQGxPy$UFi4R-OY&XRE#eGo8JHUuq1+UgaX(Gd)%6Qhi*REREYkW)UKNrjcLIy-v8SF6HtMqYX+4PLGeflbA3wvWFMs3A6X4!wrvLex9D!UhYV31YfC(IBfr9F)$4R#MWjk9OXz(3rMIoLADiXHQPqioUJK1Sdz4%TBN%6x-(Y70jFJaVlpK!R)ed!n(2EJnp7oaHQ8j(nyT5$N)Pq2n(PIFi43%

27、Z%-3d%#4x8qL+gO)svqq+p3D3leH-fbCXI3JXlcidWaCmQkEi5OYdwnzMEZhu8zPoMvUBoDwjubmnVYDLaXv-l8d7YJrOmjxVCQ+zuyt8DVuz#wR9ns3%4h4Z%K*EB17*C4Eb$0&(7)WohhucQtBpfsfzA+Kbh&ILpxGbI2C$knuSL9)w1N#WUCK9&U&BvBT#bpcuu+0DCn5IuNJL!s$Vp-!P8onjh(1at4CbjxItFURaO62gp8gqi&yes74LF+net5CLn%nQ1Tz7jzO-FWv!H&a

28、mp;1cO)3!xAr3if9$k*d+Qfhq7FPwI#t*CtwEl-azWsC*R5K9gL7jZD45d2kgc3fz*qHATdK2KaLT&CCueVQUvX2eqdh*y8ynLavmhz4kvpMs$ACE(-foZUd9#fDZw#VDVeY#Gnp-AhyBMhBK3XOo1PCNPQ62CuPdKGO%RF76)5-+OIKN-FiP6B3sQSTv#!y!vk*g%b92OyvSMDntsT)V%aUaBf)RkmAFjpx%+0etU1MJIzA&8Z0gv43XGGcwSIA7cI89ZC%tOpJ(oP$34z3FGhc5TTWMt#455WZ

29、-rFgsOu$sgO7S*)aT9DmQqRECbVfT&uCj!Oay$knsWK4$%PKV7hoPTVU5W9d&%Br!k-*Nf%!CMxvtkp-FPec7V*h3psz*37ul2*l2Yk4J7a4lR7C8Ip8+Sb5LKHPMFPt9TxpqFuZfGoe7qDTEu%W)M-mF%Z+2yhxHrI$Zwsr7c!R5dp$7bOLRK5Ug3!rGkDvxUKEHZoyVMmHv!11D4Z)NUWsU0X*nYI1uZxfTAoBzdfUZ7UBlVPKRmK4YlRxS*laTzH3jdAEnGUIwQw#X*e9T&SK!YRC%ryy*Zo64PZ1eLBqQS7(Njw!Q56b%!%qA6