實證醫學文獻查證競賽 報告者 : 林祐賸醫師 嘉義長庚紀念醫院
EBM Center, CHIA-YI CHANG GUNG MEMORIAL HOSPITAL 嘉義長庚醫院實證醫學中心介紹嘉義長庚醫院實證醫學中心介紹 新生期 萌芽期 成長期 * 舉辦教育訓練 *workshop 認證 * 聘請外院專業講師 * 培訓種子老師 * 定期團隊會議 * 舉辦實證共識營 * 醫學演講實證化 * 建置專科資料庫 * 實證臨床指引 * 導入臨床醫療 * 導入醫學教學 實證醫學中心的成員包含相關部門與執行單位, 除了基礎臨床醫療作業單位之外, 仍須資訊單位建置網路學習園地 圖書館人員對資料庫的搜集整理等, 均有專責人員互相緊密配合, 並且定期開會檢討 92 年成立 實證醫學中心實證醫學中心, 推動教育訓練 舉辦 EBM+PBL Tutor 種子教師研習營, 推展至各單位 小組方式教導住院醫師及實習醫學生實際演練 年度 EBM 系列課程, 推展至各醫事類人員 建構具地方醫療特色之臨床診療指引
推動實證醫學 EBM Center, CHIA-YI CHANG GUNG MEMORIAL HOSPITAL 專屬網頁 實證醫學系列課程
成長足跡成長足跡 EBM Center, CHIA-YI CHANG GUNG MEMORIAL HOSPITAL 2007 年 : 全國 78 所各級醫院競賽中, 本院初試啼聲, 榮獲醫策會第八屆實證醫學文獻查證應用進階組金獎 2009 年 : 發表論文於 EBM 標竿刊物 -Cochrane review 全國 24 所各級醫院參與第十屆實證醫學文獻查證進階組競賽, 榮獲醫策會銅獎 發表論文於標竿刊物 -Cochrane review 榮獲醫策會實證醫學文獻查證進階組金獎及銅獎
組長 組員 嘉義長庚醫院文獻查證臨床組參賽成員簡介 姓名 林祐賸 ( 報告者 ) 資歷簡介 長庚大學臨床醫學研究所準博士班現職 : 嘉義長庚醫院心臟科講師級主治醫師嘉義長庚醫院一般醫學導師嘉義長庚醫院一般醫學臨床教師實證醫學推動小組內科種子教師 陳宣雅高雄醫學大學藥理研究所碩士畢業現職 : 嘉義長庚醫院諮詢藥師 黃美華輔英科技大學護理研究所碩士畢業現職 : 嘉義長庚醫院病房副護理長嘉義長庚技術學院兼任講師實證醫學推動小組成員
臨床情境 Present illness: 實證醫學文獻查證競賽 55 歲女性有 10 年第二型糖尿病史, 最三年因血壓高, 也開始使用血壓藥物, 半年前檢查 creatinine 值為 2.5, 醫師告知腎功能稍微不好, 要特別注意 最近朋友送了一箱楊桃, 多吃了幾個 今天早上家屬發現病人嗜睡, 且不易叫醒而送醫, 急診發現 creatinine 上升到 9.0 家屬連環炮似的問了幾個問題 : 為什麼這樣? 和吃楊桃有沒有關係? 糖尿病會引起尿毒症嗎? 需不需要洗腎? 若需要洗腎血液透析或腹膜透析比較好?
臨床問題 Question Framing 問題一病患想知道需不需要洗腎?
PICO Patient Intervention Comparison Outcome 建構問題 Question Framing (Q1) 55 歲女性有 10 年糖尿病病史, 近三年血壓高, 服用血壓藥物, 半年前檢查 creatinine 值為 2.5, 今天早上發現病人嗜睡不易叫醒, 送醫急診發現 Creatinine 上升至 9.0 洗腎 不需洗腎 死亡率腎臟功能回復率 Keyword End-staged renal disease, ESRD, uremia,acute on chronic renal failure, hyperkalemia, CKD. Renal replacement therapy Renal dialysis Conservative therapy Survival Mortality, recovery of renal function
臨床問題 Question Framing 問題二病患想知道若需要洗腎, 血液透析或腹膜透析好?
PICO Patient Intervention Comparison Outcome 建構問題 Question Framing (Q2) 55 歲女性有 10 年糖尿病病史, 近三年血壓高, 服用血壓藥物, 半年前檢查 creatinine 值為 2.5, 今天早上發現病人嗜睡不易叫醒, 送醫急診發現 Creatinine 上升至 9.0 早期使用抗生素 人工皮治療 無早期使用抗生素 人工皮治療 死亡率, 腎臟功能回復率 Keyword End-staged renal disease, ESRD, uremia,acute on chronic renal failure, hyperkalemia, acute kidney injury, acute renal failure hemodialysis Peritoneal dialysis (CAPD,CCPD) Survival, Mortality, recovery of renal function
Level of evidence pyramid (for therapy/prevention, aetiology/harm) Level 1 Level 2 Level 3 Level 4 Level 5 10th July 2010 Dr Ching-Chi Chi, MD, MMS, DPhil (Oxford)
Different levels of evidence for different fields 10th July 2010 Therapy/prevention, aetiology/harm: systematic review (SR) of RCTs, RCT, cohort study,. Prognosis: SR (with homogeneity*) of inception cohort studies, validated Clinical Decision Rule (CDR) Diagnosis: SR (with homogeneity*) of Level 1 diagnostic studies; CDR Differential diagnosis/symptom prevalence study: SR (with homogeneity*) of prospective cohort studies Economic and decision analyses: SR (with homogeneity*) of Level 1 economic studies Dr Ching-Chi Chi, MD, MMS, DPhil (Oxford)
證據搜尋方法與證據等級 Search Evidence Primary Database Secondary Database PubMed Medline Cochrane Up to date MD Consult
Secondary database Primary database Search strategy Databases Indication of dialysis Acute kidney injury or acute renal failure dialysis Key word Hemodialysis and peritoneal dialysis End-stage renal disease(esrd) Acute renal injury(acute on chronic renal failure) Hemodialysis and peritoneal dialysis
Indication of dialysis
Acute renal failure or acute kidney injury
Acute on chronic renal failure So, 這個病人視為 acute on chronic renal failure
Indication of dialysis
Dialysis in UpToDate
Conclusion of hemodialysis and peritoneal dialysis in UpToDate The results have been conflicting, with hemodialysis reportedly having no difference, a relative benefit, or a relative adverse effect upon survival compared with peritoneal dialysis In summary, additional studies are required to determine whether PD has any survival advantage or disadvantage as a dialysis modality in the management of end-stage renal disease, particularly with respect to age, time after initiation of dialysis, and comorbid condition.
Searching in Cochran Library
Searching in Cochrane Library
Searching in PubMed-listing
Searching result in Pubmed -acute renal failure or acute kidney injury+dialysis+ hemodialysis and peritoneal dialysis
Searching results Databases Pathway returns 1/1 1/4
Continuous peritoneal dialysis compared with daily hemodialysis in patients with acute kidney injury
解讀證據 Critical Appraisal 文獻結果是否有效度 :Validity 文獻結果是否有臨床重要性 :Importance 文獻結果是否適用於我們的病人 :applicability
文獻評讀 Basic information about the trial First author Publication year Title Country Funding source Daniela Ponce Gabrie 2009 CONTINUOUS PERITONEAL DIALYSIS COMPARED WITH DAILY HEMODIALYSIS IN PATIENTS WITH ACUTE KIDNEY INJUR State University Nil
Participants/ Problem Intervention Comparison Outcome Study design What is the trial about? A total of 120 patients with acute tubular necrosis(atn) Cr:<3 and receive CPD receive dhd 1.The two groups were similar in metabolic and acid base control the survival rate did not differ between the groups (58% in G1 vs 52% in G2) 2.Recovery of renal function was similar (28% vs 26%). RCTs
Item Are the results of the trial valid? 1. Was the assignment of patient to interventions randomised? 2. Was the randomisation concealed? 3. Were the groups similar at the start of the trial? 4. Was follow-up of patients sufficiently long and complete? Appraisal Yes No Unclear Yes No Unclear Yes No Unclear Yes No Unclear Comments
Item Are the results of the trial valid? 5. Were all patients analysed in the groups to which they were randomised? (intention-to-treat analysis) 6. Were measures objective or were the patients and clinicians kept blind to which intervention was being received? 7. Were groups treated equally, apart from the experimental therapy? Appraisal Yes No Unclear Yes No Unclear Yes No Unclear Comments
Are the results of the trial valid?
Item If the results of the trial are valid, how important are they? What is the magnitude of the intervention effect? How precise is the estimate of the intervention effect? Results Comments 兩組均為 60 人 5% (p < 0.05) significance level
Are the results of the trial important?
Can we apply them to our patients? Item Appraisal Comments Is our patient so different from those in the study that its results cannot apply? Is the intervention feasible in our setting? Yes No Unclear Yes No Unclear In this patient, acute on chronic renal failure
Can we apply them to our patients? Item Appraisal Comments What are our patient s potential benefits and harms from the therapy? Benefits: decreased K level, recovery of renal function, glucose control. Harms: infection rate, mechanical support
Outcome Figure 2 Comparison of metabolic control in high-volume peritoneal dialysis (HVPD) and daily hemodialysis (dhd), showing median serum levels of (a) blood urea nitrogen (BUN), (b) creatinine, (c) bicarbonate, (d) potassium, (e) sodium, and (f) glucose at the start of treatment and after each dialysis session. * p > 0.05 for HVPD as compared with DHD at each session.
complications
Can we apply them to our patients? Item Appraisal Comments What are our patient s values and expectations for both the outcome we are trying to prevent and the intervention we are offering? Patient s values: 需要洗腎
Cost
Applying to our patient 整合實證 ---運用於臨床決策 治療計畫建議 治療計畫建議 我們給予的建議是 我們給予的建議是 病患應該接受洗腎治療 病患應該接受洗腎治療 腹膜透析 及血液透析均可改善病患腎臟功能 每天的腹膜透析對於 血糖控制效果也較好 血糖控制效果也較好 對於台灣健保局而言腹膜透析價 錢相對便宜 因此 建議病患可執行腹膜透析 建議病患可執行腹膜透析 也建議病 患須注意自身血糖控制避免潛在危險性 患須注意自身血糖控制避免潛在危險性
嘉義長庚紀念醫院 Chang Gung Memorial Hospital Welcome to CGMH, Chia-Yi p122219@cgmh.org.tw