Internet Access to EvidenceBased Information TEBMA Taiwan Evidence

Internet Access to Evidence-Based Information 實證文獻搜尋簡介 TEBMA (Taiwan Evidence Based Medicine Association)

*"Kill as Few Patients as Possible" - Oscar London 5, 000? per day 95 per day 2009 1, 400 per day NCKUFM-YCY

266, 000 Evidence based 2009 NCKUFM-YCY

如何檢視實證資源 l be up to date (< 1 year old) l state how it searches for evidence l state how it appraises evidence l state what the evidence is and provide a reference l state the level of evidence in support of its recommendations 2009 NCKUFM-YCY

Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009) Level Therapy / Prevention, Aetiology / Harm Prognosis Diagnosis Differential diagnosis / symptom prevalence study Economic and decision analyses 1 a SR (with homogeneity*) of RCTs SR (with homogeneity*) of inception cohort studies; CDR† validated in different populations SR (with homogeneity*) of Level 1 diagnostic studies; CDR† with 1 b studies from different clinical centres SR (with homogeneity*) of prospective cohort studies SR (with homogeneity*) of Level 1 economic studies 1 b Individual RCT (with narrow Confidence Interval‡) Individual inception cohort study with > 80% followup; CDR† validated in a single population Validating** cohort study with good††† reference standards; or CDR† tested within one clinical centre Prospective cohort study with good follow-up**** Analysis based on clinically sensible costs or alternatives; systematic review(s) of the evidence; and including multiway sensitivity analyses 1 c All or none§ All or none case-series Absolute Sp. Pins and Sn. Nouts†† All or none case-series Absolute better-value or worse-value analyses †††† 2 a SR (with homogeneity*) of cohort studies SR (with homogeneity*) of either retrospective cohort studies or untreated control groups in RCTs SR (with homogeneity*) of Level >2 diagnostic studies SR (with homogeneity*) of 2 b and better studies SR (with homogeneity*) of Level >2 economic studies 2 b Individual cohort study (including low quality RCT; e. g. , <80% followup) Retrospective cohort study or follow-up of untreated control patients in an RCT; Derivation of CDR† or validated on splitsample§§§ only Exploratory** cohort study with good††† reference standards; CDR† after derivation, or validated only on splitsample§§§ or databases Retrospective cohort study, or poor follow-up Analysis based on clinically sensible costs or alternatives; limited review(s) of the evidence, or single studies; and including multi-way sensitivity analyses 2 c "Outcomes" Research; Ecological studies "Outcomes" Research Ecological studies Audit or outcomes research 3 a SR (with homogeneity*) of case-control studies SR (with homogeneity*) of 3 b and better studies 3 b Individual Case-Control Study Non-consecutive study; or without consistently applied reference standards Non-consecutive cohort study, or very limited population Analysis based on limited alternatives or costs, poor quality estimates of data, but including sensitivity analyses incorporating clinically sensible variations. 4 Case-series (and poor quality cohort and casecontrol studies§§) Case-series (and poor quality prognostic cohort studies***) Case-control study, poor or non-independent reference standard Case-series or superseded reference standards Analysis with no sensitivity analysis 5 Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles" Expert opinion without explicit critical appraisal, or based on economic theory or "first principles" Centre For Evidence-Based Medicine Levels of Evidence http: //www. cebm. net/? o=1116 2009 7 NCKUFM-YCY Not all evidence is equal: hierarchy of evidence

終身學習 Push 備用學習 Just in Case learning Pull 即時學習 Just in Time Learning Be Expertise in your field

Coping with the overload: 1. Read an evidence-based abstraction journal (and cancel other journals) 2. Keep a logbook of your own clinical questions 3. Run a case-discussion journal club with your practice 2009 NCKUFM-YCY

How can I have best evidence find me? Push & Prompt” “ Resources 2009 NCKUFM-YCY

http: //medlineplus. gov 2009 NCKUFM-YCY

Medline. Plus Health News (Health. Day stories and press announcements) 2009 NCKUFM-YCY

Medline. Plus E-mail Announcement Lists l Subscribe to these general Medline. Plus listservs that cover all health topics: n n n l Specialty Topics (weekly) : n n n n 2009 MEDLINEPLUS-NEW (Weekly) - includes all new resources, health topics, and announcements. MEDLINEPLUS-NIH (Weekly) - includes only new and updated consumer health information from the National Institutes of Health, plus announcements and new health topics. MEDLINEPLUS-NWS (Daily) - includes all news headlines published on MEDLINEplus. Children Diabetes Environmental Health Men's Health Mental Health Nutrition & Healthy Eating Senior's Health Women's Health NCKUFM-YCY

路透社消息 2009 NCKUFM-YCY

Nutrition News from Medline plus l l l l l 2009 Health Tip: Making Better Choices for Fast Food (06/08/2009, Health. Day) Healthy Diet May Boost Men's Fertility (06/08/2009, Reuters Health) Want to Stop Cancer? You Can, Experts Say (06/03/2009, Health. Day) Summer Fruits and Veggies (06/01/2009, Centers for Disease Control and Prevention) Americans Score Low on Healthy Lifestyle (05/27/2009, Health. Day) Too Much Cola Can Cause Muscle Problems (05/27/2009, Health. Day) Skip the Burgers and Throw Some Veggies on the Grill (05/22/2009, Health. Day) Coffee in Pregnancy May up Cleft Lip Risk Slightly (05/06/2009, Reuters Health) More Educated Choose Healthier Foods, But Pay More (05/01/2009, Health. Day) Healthy Items on Menu Make Unhealthy Picks Easier (04/30/2009, Reuters Health) Plant-Based Flavonoid May Cut Ovarian Cancer Risk (04/22/2009, Reuters Health) Soy May Not Lead to Denser Breasts (04/22/2009, Health. Day) Fructose-Sweetened Drinks Up Metabolic Syndrome Risk (04/20/2009, Health. Day) U. S. Nutritionists Urge New, Not-As-Sweet Drinks (04/20/2009, Reuters Health) Broccoli May Ward Off Serious Stomach Ailments (04/06/2009, Health. Day) Antioxidant-Rich Foods Lose Nutritional Luster Over Time (04/02/2009, Health. Day) Fast-Food Diners Don't Check Calorie Content (03/26/2009, Reuters Health) Urine Test May ID Unhealthy Diets (03/26/2009, Health. Day) Too Much Red Meat May Shorten Life Span (03/23/2009, Health. Day) Also see Medline. Plus Nutrition NCKUFM-YCY

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訂閱ADA newsletters (每週四) 2009 NCKUFM-YCY

Where can I find current best evidence? Pull” Resources “ (ie, information sources that allow you to find current best evidence) 2009 NCKUFM-YCY

“ 5 S ” Information Resources 系統 Systems 綜結 Summaries 精要 Synopses 統整 Syntheses 研究 Studies Computerized Decision Support System (CDSS) 電腦化的決策支持系統 Evidence based textbooks Up. To. Date, Dyna. Med, ACP PIER BMJ Clinical Evidence based journals EBM, EBN, EBMH, ACP J club Systematic Review Cochrane reviews BMJUpdates+ Pub. Med Clinical Queries Original articles Haynes, R. (2006, November). Of studies, syntheses, synopses, summaries, and systems: the 5 S evolution of 2009 NCKUFM-YCY information services for evidence-based health care decisions. ACP Journal Club, 145(3), A 8 -A 9.

System Summaries Synopses Synthesis Studies Systems Computerized Decision Support System (CDSS) 2009 NCKUFM-YCY

Summaries – System Summaries Synopses Synthesis Studies l 2009 examples of evidence-based textbooks Evidence-Based specialty texts (eg BMJ series) NCKUFM-YCY

Summaries – System Summaries Synopses Synthesis Studies 2009 examples of evidence-based textbooks l Up. To. Date (www. uptodate. com) l Clinical Evidence (www. clinicalevidence. com or OVID) l Physician Information and Evidence Resource (pier. acponline. org or Stat!Ref: www. statref. com) l Evidence-Based specialty texts (eg BMJ series) l Evidence-Based On-Call (www. eboncall. org) NCKUFM-YCY

www. uptodate. com 2009 NCKUFM-YCY

Up. To. Date 26 Up. To. Date之使用 ① 檢索可以一個或多個關鍵字、詞句或問題。 Ex: treatment of raynaud’s disease in women patient info raynaud’s disease—特別檢索病患資訊 ② 瀏覽檢索結果。 ③ 利用Outline快速瀏覽，Summary and Recommendations提 供摘要與建議，閱讀實證等級。 ④ 檢索歷史回顧。 2009 http: //www. uptodate. com/home/index. html 26

Dyna. Med 2009 http: //www. ebscohost. com/dynamed/ Dyna. Med 匯總了近 2, 000個醫學臨床 課題 ① 主題檢索。 ② A-Z瀏覽。 ③ 全文檢索。 ④ 學科瀏覽。 ⑤ 檢索結果資訊包含：病況描述( 涵蓋 ICD-9/10 codes), 造成原因 及危險因子(Causes & Risk Factors), 併發症及相關表徵 (Complications & Associated Conditions), 病況歷史(History), 身體狀態(physical), 診斷 (Diagnosis), 預後(Prognosis), 治 療(Treatment), 防治及篩選 (Prevention & Screening), 參考文 獻 (包括評論(Reviews)及指南 (Guidelines)), 病患資料(Patient 27 Information)等。

Clinical Evidence Free on-line access for physicians in the UK or in developing countries. 2009 http: //clinicalevidence. bmj. com/ceweb/index. jsp Clinical Evidence 選取基礎醫療常見 的 臨 床 問 題 ， 收 集 來 自 Cochrane Library、MEDLINE、EMBASE 和實證 醫學期刊研究的報告結果，提供系 統性文獻評論(Systematic Reviews)、 隨機取樣的臨床對照試驗(RCTs)及觀 察研究(Observational Studies)證據。 Clinical Evidence之使用 ① 使用Sections按主題瀏覽；Full Review List依據A-Z選單瀏覽；站 內檢索Search this Site。 ② Conditions以症狀瀏覽。 ③ 瀏覽檢索結果內容： Interventions提供不同療法之利 弊比較；About this condition提 供症狀/疾病之定義、傳播、風 險因子、預後、治療目的、結 果、方法；Updates資訊、 29 Guidelines、Reference。

System Summaries Synopses Synthesis Studies 2009 Synopses examples NCKUFM-YCY

EBM Solution, ACP Journal Club：提供臨床實證醫 學文獻資訊 ① Advanced Search ② Filter by text type 依據內文類型 篩選 ③ 檢索包含英文字字尾變化 ④ Search Sets依據類別分類檢索 ⑤ 瀏覽EBM Solution資源 2009 31

System Summaries Synopses Synthesis Studies l l Critically Appraised Papers (CAPs) Critically Appraised Topics (CATs) n n l l 2009 University of Rochester Medical Center (CATs) University of Michigan Paediatrics (CATs) University of Washington (CATs) Best. BETs (CATs) (Best Evidence Topics) Patient-Oriented Evidence that Matters (POEM) n l Critically appraised Resources The Journal of Family Practice, which reviews 7 -10 articles from the primary care literature each month as part of POEMs Peds. CCM Evidence-Based Journal Club, which reviews clinical trials relevant to paediatric care. Evidence-Based on Call NCKUFM-YCY

Bandolier http: //www. medicine. ox. ac. uk/bandolier/ 2009 http: //www. medicine. ox. ac. uk/bandolier/knowledge. html Bandolier Knowledge Library提供 實證醫學資料包括：治療主題相 關之系統性評論，診斷證據，健 康經濟或流行病學等，資訊類型 包含：Systematic reviews, metaanalyses, randomised trials, and from high quality observational studies. ①關鍵字檢索 ②A-Z 瀏覽 33

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Essential Evidence Plus (Formerly Info. POEMs) 2009 http: //www. essentialevidenceplus. com/ Essential Evidence Plus包含EBM Guidelines、Daily POEMs、Cochrane Abstracts 、Selected Practice Guidelines 、Decision Support Calculators 、H&P Calculators 、Diagnostic Test Calculators 、Derm Expert 、E/M Coding 、ICD-9 Lookup Tool。 ①檢索 ②依據主題分類瀏覽檢索結果。 ③依據檢索結果類型瀏覽檢索結果，亦提供依據 資源分類瀏覽檢索結果。 35 ④檢索結果提示證據等級。

System Summaries Synopses Synthesis Studies Syntheses: Examples l http: //www. cochrane. org/reviews/ l Pub. Med Clinical Queries “Systemic Reviews” or Ovid Clinical Queries “Review” search strategy 2009 NCKUFM-YCY

Systematic Reviews 檢索策略 • Systematic[sb]等於 2009 NCKUFM-YCY

System Summaries Synopses Synthesis Studies (look for these when you can’t find the information you need in a system, synopsis, or synthesis) Clinical Queries 2009 NCKUFM-YCY

http: //www. pubmed. com http: //www. pubmed. gov http: //www. pubmed. net http: //www. pubmed. org http: //www. ncbi. nlm. nih. gov/entrez/query. fcgi 2009 NCKUFM-YCY

Clinical Queries Methodology Filters 2009 NCKUFM-YCY

Pub. Med—檢索詞彙修正參考 Search Keyword Search Pub. Med Select Me. SH Database 2009 Send to Search Box with AND/OR/NOT Search other Me. SH and repeat Link Pub. Med Major Topic NCKUFM-YCY 43

Pub. Med—檢索詞彙修正參考 Browse Details Check Translations for Searched Me. SH Display Citations Browse Article's related Me. SH 2009 NCKUFM-YCY 44

Pub. Med—篩選資料 Register Personal Account Results Filter by Setting Click Choose Filter Add Filter Function to 2009 Personal Environment. NCKUFM-YCY 46

實用技巧-布林邏輯與運算元 萬用字元符號於每個資料庫定義不同，需針對個別資料庫設定而使用 OVID範例 運算元 OR l(pregnancy or birth). ti. l 1 or 2 or 3 or 5＝or/1, 2, 3, 5＝or/1 -3, 5 AND l(pregnancy and birth). ti. l 1 and 2 and 3 and 5＝and/1, 2, 3, 5＝and/1 -3, 5 Not 排除 l(education not patient education). ti. lsafety not patient safety. ti. ⇒safety. mp not patient safety. ti lsafety not patient safety⇒safety. mp not patient safety. mp l 1 not 2 Adj. N 指定距離 lphysician adj 5 relationship l(information adj 3 retrieval). tw. Freq 關鍵字出現 頻率 lblood pressure. ab. /freq=10 l(information adj 3 retrieval). tw. /freq=5 一次僅指定一個欄位；且組合型欄位如SO無法使用Freq. 成功大學圖書館醫學院分館，2008 -07 -09(三)「實證醫學/護理在Medline」教育訓練會，飛資得資訊股份有限公司李紹迪小姐主講。 2009 NCKUFM-YCY

System Summaries Synopses Synthesis Studies EB Shopping Mall: ex. 1 Systems, linked summaries, synopses, studies Ovid has the best collection of evidence-based information, especially in its Evidence-Based Medicine Reviews collection. summaries studies synopses synthesis 2009 NCKUFM-YCY

System Summaries Synopses Synthesis Studies EB Shopping Mall: ex. 2 Systems, linked summaries, synopses, studies 1. 2. 3. 4. 5. 6. 7. 8. 9. 2009 Clinic Books Journals Drugs News Current Practice Patient Handouts Student Union MDC Mobile NCKUFM-YCY

Clin-eguide Clin-eguide前身為Skolar MD Clinical. Resource@Ovid，包含豐富臨床資 源、實證醫學與藥學的整合系統，核心資源包括：Clin-eguide Evidence. Based Medicine、EBM Articles 、National Guideline Clearinghouse 、 Aulstraliz/New Zealand Guideline 、Ebook ex: 5 -Minute Consult Datebase 、 Books@OVID 、Medline 、Nurisng Advisor 、Journal@OVID、 Drug Facts & Comparisons等藥典資源。 ① 自然語言檢索 ② 整合多資源檢索 ③ 依照需求資源個別檢索 ④ 藥物資訊快速查詢 ⑤ 其他 具：快速診斷、ICD 9、醫學公式速查 具 2009 51

US National Guidelines Clearinghouse (NGC) 2009 http: //www. ngc. gov/ The National Guideline Clearinghouse為美國Evidence. Based Clinical Practice Guidelines資 料庫，包含Structured Abstracts ， 連結Full-Text Guidelines ，並提供 Guideline比較 具。 檢索方式包括： ①主題檢索：Detailed Search, Frequent Searches of Frequently Requested Topics ②瀏覽By Disease/Condition, Treatment/Intervention, Measures, etc. ③Guideline比較 52

CMA Infobase: Clinical Practice Guidelines(CPG) CMA Infobase為加拿大Evidence. Based Clinical Practice Guidelines資 料庫。 檢索方式包括： ①關鍵字檢索 ②Advanced Search利用Limits篩選資 料，例如：Specialty、Domain如 Diagnosis、Treatment 、 Target Gender 2009 http: //www. cma. ca/index. cfm/ci_id/54316/la_id/1. htm 53

UK National Library of Health (NLH) 2009 http: //www. library. nhs. uk/default. aspx 54

Summary: Access to Evidence-Based Information l Push l Pull System Summaries Synopses Synthesis Studies l 2009 Prompt…. . some labs and e. MRs with a credible evidence-based pedigree NCKUFM-YCY