【正文】 非治療必需」，而應(yīng)考慮手術(shù)治療，故不予同意使用。其病理組織切片檢查報(bào)告顯示為 adenomyosis 與 endometriosis。 109: 67884 ? Probiotics in prevention of antibiotic associated diarrhea: metaanalysis BMJ 2021。 故長(zhǎng)期飲用 LGG 牛奶 , 每 100 位可避免其中 8 位得到嚴(yán)重的呼吸道感染 換言之 , 每治療 12 位 , 可拯救其中 1 人 : Number needed to treat to prevent one failure (NNT) = 12 = 1 / ARR Why use NNT? 假設(shè)有下列三種情況 : Situation: LGG Control RRR NNT 1 本研究中的患者 39% 47% 17% 12 2 患者病情輕微 % % 17% 125 3 患者病情嚴(yán)重 78% 94% 17% 6 ? 雖然 LGG 在三類患者療效 (RRR) 相同 , 但在抵抗力較差的小朋友飲用 LGG, 只要治療較少的小朋友 , 即可多拯救 一人 (NNT較小 ), 故可知治療應(yīng)考慮患者的 baseline risk。 physicians were blinded to the results of EMTD. All other lab results (might include AFB smears) were available. ? Reference standard: ? Definite active TB: high clinical suspicion (80%) and ≧ 2 positive cultures ? Definite absence of active TB: low clinical suspicion (10%) without any positive culture ? Otherwise, the cases were reviewed by the independent expert panel: at least 2 of the 3 members had to consider the patient to have or to be free of TB JAMA 2021。 82: 1317 ? Workup bias The result of the test may affect the subsequent clinical workup needed to establish the diagnosis… Verification Bias or Workup Bias Test Reference standards Total Reference standards Total Dz No Dz Dz No Dz Pos 80 100 180 80 100 180 Neg 20 900 920 2 90 92 Total 100 1000 1100 82 190 272 Sensitivity = 80% Specificity = 90% Sensitivity = 80/82 = 98% Specificity = 90/190 = 47% Oxford Center for EBM Levels of Evidence Level Diagnosis 1a SR (with homogeneity) of Level I diagnostic studies 1b Validating cohort study with good reference standards 1c Absolute SpPins and SnNouts 2a SR (with homogeneity) of Level II diagnostic studies 2b Exploratory cohort study with good reference standards 3a SR (with homogeneity) of 3b and better studies 3b Nonconsecutive study。 38: 3150 – 3155 ? 利用 TBPCR檢查 診斷結(jié)核性肋膜炎及其他肺外結(jié)核 ? Chest 1998。 CDR) ? Tools that quantify the individual contributions 。 這時(shí)有什麼辦法來(lái)幫助我們提高肺結(jié)核的診斷率 ?? 多重試驗(yàn) (平行試驗(yàn)或序列試驗(yàn) ) 在此時(shí)有幫助嗎 ? 若 TBPCR的結(jié)果為陰性 (或陽(yáng)性 ), 對(duì)我們的處理有什麼影響 ? Evidence is never enough… ? 利用 CSF TBPCR檢查 快速診斷結(jié)核性腦膜炎 ? J Clin Microbiol 1998。4:5524 ? Testreview bias A test that is interpreted subjectively can be biased by the knowledge of the diagnosis ? Value of infarctspecific isotope (99m Tclabeled stannous pyrophosphate) in myocardial scanning. BMJ 1975。 三天後發(fā)生咳嗽 、 發(fā)燒 、 氣促等癥狀 … ? WBC: 14000/mm3 ? CxR:↑ infiltrate over bilateral lower lung ? Sputum Gram stain: G(+) cocci with phagocytosis ? Sputum Acidfast stain: few acidfast bacilli ?? 臨床診斷常犯的錯(cuò)誤 ? 以為檢查結(jié)果為陽(yáng)性就能 100%的確定患者有病 ? 忽視了患者罹患該疾病的基本可能性 (prior probability) ? 不了解診斷工具本身的特性 (敏感度、特異度 ) ? 重複地選擇不會(huì)影響患者處置的檢查 What we will learn today… ? Step 1: 如何明確的分析我們所面臨的臨床問(wèn)題 ? ? Step 2: 證據(jù)在哪裡 ? 如何有效率的搜尋文獻(xiàn) ? Step 3: 臨床研究的結(jié)果可信嗎 ? ? Step 4: 其臨床意義為何 ? ? Step 5: 我該如何利用臨床研究的結(jié)果照顧我的病人 ? How to ask a meaningful question? “學(xué)長(zhǎng) , 我們是不是直接就要開始讓病人接受抗結(jié)合藥物的治療 , 還是先安排她做痰液的TBPCR檢查 ?” Step 1: 如何明確的分析我們所面臨的臨床問(wèn)題 ? The specific,answerable clinical question: ? Patients ? Intervention vs. ? Comparison ? Outes Step 2: 證據(jù)在哪裡 ? 如何有效率的搜尋文獻(xiàn) The role of clinical suspicion in evaluating a new diagnostic test for active tuberculosis ? Design: Prospective cohort study ? Setting: 6 medical centers and 1 public health TB clinic between Feb and Dec 1996. ? Participants: ? 425 patients suspected of having active pulmonary TB based on symptoms, risk factors, PPT test, CxR findings. ? Identified by chest or ID specialist. ? Not eligible if they received multidrug treatment for TB for ≧ 7 days during the past 3 months. JAMA 2021。 42: 3015 Clinical characteristics of study and control groups Study group (n = 50) Control group (n = 50) p Age, mean, SD (m/o) () (10) Duration of diarrhea at home (day) () () Dehydration % % Oute of therapy Study group Control group p Diarrhea frequency Day 0 () () Day 1 () () Day 2 () () Duration of diarrhea in hospital (day) () () Recovery rate on the 2nd day 52% 18% What were the results? LGG (n = 252) Control (n = 261) p Any illness (days) 25 (22 – 28) 27 (24 – 30) Respiratory symptoms (days) 21 (18 – 24) 23 (20 – 26) GI symptoms (days) ( – ) ( – ) Absence due to illness (days) ( – ) ( – ) Acute otitis media 31% 39% Sinusitis 3% 4% Acute bronchitis 6% 7% Pneumonia 1% 2% All infection together 39% 47% Antibiotic treatment 44% 54% 研究的結(jié)果可有不同的方式表達(dá) Oute LGG Control p ARR (95%.) NNT All respiratory infection 39% 47% % ( ~ ) 12 Antibiotic treatment 44% 54% % ( ~ ) 10 Absolute risk reduction (ARR): 47% 39% = 8% Relative risk reduction (RRR): (47% 39%) / 47% = 17% 假設(shè)有 100 位小朋友在冬天的七個(gè)月內(nèi) 其中有 47 位會(huì)得到嚴(yán)重的呼吸道感染 。 J Pediatr. 1999。 案例六 31歲女性，因反復(fù)下腹疼痛及經(jīng)痛就診，經(jīng)口服藥物治療無(wú)效，近日因癥狀加劇，疑似子宮內(nèi)膜異位癥，安排住院而接受腹腔鏡手術(shù)治療。 健保局認(rèn)為該醫(yī)師未進(jìn)行詳細(xì)神經(jīng)學(xué)檢查，且在此案例中 CT為非必要之檢查。 如 : 這個(gè)病真的需要開刀嗎 ?不開刀會(huì)怎樣 ?) 五、 效益 costeffectiveness問(wèn)題 … 按 Patients Intervention Comparison Oute 做更明確的描述 (Answerable clinical questions) *請(qǐng)注意什麼是目前的照護(hù)標(biāo)準(zhǔn) Standard of care Clinical scenario (I) ? 林先生 , a 60 y/o cook, visited ER due to increased productive cough and dyspnea for 3 days ? COPD diagnosed for 3 years。何謂實(shí)證醫(yī)學(xué) 臺(tái)大內(nèi)科 張家勳 MD, MSc in Clinical Epidemiology Email address: Our Goals… 觀念澄清 ? 什麼是 “ 實(shí)證醫(yī)學(xué) ” ? ? 為什麼要推動(dòng)實(shí)證醫(yī)學(xué)教學(xué) ? ? 實(shí)證醫(yī)學(xué)教學(xué) 和一般教科書上談的知識(shí) 有什麼不一樣 ? 平常醫(yī)師是如何去診斷、治療患者 ? 醫(yī)生 , 請(qǐng)問(wèn) … ? “我到底有沒有病 ?” ? “我該不該吃藥 ?” ? “我一定要開刀嗎 還有沒有更好的方法 ?” ? “我還能活多久 ?” ? 臨床上面臨的問(wèn)題有許多不確定性 , 這種不確定性是以機(jī)率來(lái)表示 ? 機(jī)率的估計(jì) 可以來(lái)自個(gè)人以往的經(jīng)驗(yàn) , 但免不了有某種程度的偏差 ? 沒有任何一位臨床醫(yī)師擁有完全足夠的臨床經(jīng)驗(yàn) , 可辨識(shí)大部分慢性病之間細(xì)微又長(zhǎng)期的互動(dòng)關(guān)係 53 位 COPD AE 患者接受吸入性支氣管擴(kuò)張劑及一種實(shí)驗(yàn)藥物治療 , 六個(gè)小時(shí)後 , 患者的癥狀有顯著改善 。 目前的證據(jù)未必是完美的 , 絕對(duì)正確的 ? 將來(lái)有