1 / 35

情境題目

?. ?. ?. 一位 1 歲的寶寶由父母親帶來我小兒科求診 , 此次因下呼吸道感染由主治醫師收住院治療 , 過去該兒童曾在中部的醫學中心因肺炎住過院 , 父母親對於此次住院時開立的蒸氣吸入治療 (0.9% Sodium Chloride) 與醫學中心 (3% Sodium Chloride) 的製劑濃度不同 , 故想知道這兩種霧化吸入溶液治療效果的差別。. 情境題目. Foreground questions (Treatment).

Télécharger la présentation

情境題目

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. ? ? ? 一位1歲的寶寶由父母親帶來我小兒科求診,此次因下呼吸道感染由主治醫師收住院治療,過去該兒童曾在中部的醫學中心因肺炎住過院,父母親對於此次住院時開立的蒸氣吸入治療 (0.9% Sodium Chloride) 與醫學中心 (3% Sodium Chloride) 的製劑濃度不同,故想知道這兩種霧化吸入溶液治療效果的差別。 情境題目

  2. Foreground questions (Treatment) • In children with lower respiratory tract infection, is inhalation 3% sodium chloride better than 0.9% sodium chloride in shortening hospital stay ? (兒童下呼吸道感染霧化吸入治療中, 關於縮短住院天數, 3%食鹽水是不是比0.9%食鹽水好 ?)

  3. ASKING ~ PICO

  4. Key Words & MeSH

  5. EBM 子曰:我非生而知之者,好古,敏以求之也

  6. ACQUIRING ~ Databases • Unfiltered / Primary Database - - • Prefiltered / Secondary Database - - - - - -

  7. Clinical queries:Nebuliz* hypertonic saline + therapy (category) + narrow, specific search (scope)  26篇 • Limit: Humans, Randomized Controlled Trial, Review, All Child: 0-18 years  12篇 PubMed Search ACQUIRING ~ Databases

  8. Cochrane Library 搜尋策略 : Advance search  • 1 (respi* infection OR bronchiolitis OR bronchitis OR pneumonia AND inhalation)in Title, Abstract or Keywords  6315 篇 • 2 (hypertonic saline AND therap* NOT cystic fibrosis)in Title, Abstract or Keywords  252篇  #1 and #2

  9. Cochrane Library

  10. ACP Journal Club • 搜尋策略 keywords: • hypertonic saline inhal* AND child* AND infection No matches. • hypertonic saline (inhal* OR nebuli*) 1篇

  11. National Guideline Clearinghouse • 搜尋策略  Key ward: hypertonic saline solution inhal* 1 related guideline.

  12. DynaMed • 搜尋策略  Key ward: hypertonic saline solution inhal* AND child* AND infection7 Documents

  13. Studies Extraction ACP Journal Club PubMed Cochrane DynaMed 1 12 + 1 link 9:CT 1:Review 7 Duplication 5 Excluded articles from title and abstract 13 6 Excluded articles from full text 1 Excluded articles from study quality Review study: 1 RCT study: 4 Guideline: 1

  14. Cochrane Database of Systematic Reviews 2008, Issue 4 Level of evidence : 1a

  15. Oxford Centre for Evidence-based Medicine Levels of Evidence

  16. 文獻評讀 Critical appraisal topic

  17. APPRAISING ~ Critical Appraisal Skills Programme (CASP) Systemic Review ~ Screening Questions • Is the study valid ? What are the results ? Will the results help locally ?  Validity, Importance, Practice. Q1: Didthe review ask aclearly-focused question ? • Yes, PICO P: Children with viral bronchiolitis. I: Inhalation 3% sodium chloride. C: Inhalation 0.9% sodium chloride. O: Reduce the length of hospital stay and clinical severity score.

  18. Systemic Review ~ Screening Questions Q2: Did the review include the right type of study ? • Yes, 4 studies randomized, double-blind, parallel-group, controlled trials.

  19. Systemic Review ~ Detailed Questions Q3: Did the reviewers try to identify all relevant studies?  Yes, 261 citations  7 potenitally relevant  4 met all the criteria.

  20. Systemic Review ~ Detailed Questions Q4: Did the reviewers assess the quality of the included studies ?  Yes, 2 assessors, Jadad scoring system.

  21. Systemic Review ~ Detailed Questions Q5: If the results of the studies have been combined, was it reasonable to do so?  Yes

  22. The 3% saline group also had a significantly lower post-inhalation clinical score than the 0.9% saline group in the first three days of treatment. The effect of nebulized hypertonic saline in improving clinical score was greater among outpatients than inpatients. Systemic Review ~ Detailed Questions Q6: How are the results presented and what is the main result ?

  23. Clinical bottom line Nebulized hypertonic saline(3%) appears more effective than nebulized normal saline in reducing symptoms and shortening hospital stay in children with viral bronchiolitis.

  24. J Pediatr 2007;151:266-70 Chest 2003;123;481-487

  25. Systemic Review ~ Detailed Questions Q7: How precise are these results ? Nebulized 3% saline had a significantly shorter mean length of hospital stay compared with nebulized 0.9% saline mean difference -0.94 days, 95% CI -1.48 ~ -0.40, P = 0.0006.

  26. Systemic Review ~ Detailed Questions Q8: Can the results be applied to the local population ? • Yes • 主診斷或次診斷為 Acute bronchiolitis (ICD-9: 46619),近三年來占兩歲以下總案例數的百分比:

  27. Systemic Review ~ Detailed Questions Q9: Were all important outcomes considered ? • Yes • Length of hospital stay • Clinical severity score

  28. Systemic Review ~ Detailed Questions Q10: Should policy or practice change as a result of the evidence contained in this review ? • Yes, nebulized hypertonic saline (3%): • Length of hospital stay: 但可否縮短 25.9% 的住院天數,需額外考量國情及醫療保險的制度. • Improving clinical score was greater among outpatients  OPD.

  29. 以去學術化術語的方式回答病人的問題 假如你(妳)的寶寶得到病毒性細支氣管炎,蒸氣治療使用3% sodium chloride,大約每治療14~20個人中就可以看到 縮短住院天數 這個差異。

  30. Cough suppressant and pharmacologic protussive therapy: ACCP evidence-based clinical practice guidelines. Chest 2006 Jan;129 (78 references)

  31. 影響 • 病人:縮短住院天數, 降低院內感染機率; 改善臨床嚴重度, 降低痛苦 • 病人家屬:減少請假天數 (勞基法: 基本時薪95元) • 醫院:增加家屬滿意度  縮短病情恢復時間 縮短等待床位時間, 增加病患週轉率 健保package給付  縮短住院天數, 從健保中獲得經濟利益增加 Cost  Benefit • Reduce length of hospital stay • Improving clinical severity score 8元 × 5天 40元 • 95/01~97/12,診斷Acute bronchiolitis平均住院天數: 5.26~6.01天 (健保給付ICD9-46619, 住院4天, 6M/O-2Y/O, 16807~18455元)

  32. 醫學倫理 • Beauchamp Childress 的四大原則 • 尊重自主原則 • 行善原則 • 不傷害原則 • 正義原則 病人安全 醫療經濟利益

More Related