MD PhD MPH

(85B1)100410()15:30-17:00

Part I: (systematic review, SR) Part II: (evidence based medicine, EBM)

Part I: (systematic review, SR)

From SR to action

Modify from Straus et al.: Evidence-based medicine, Elsevier Ltd., 2005, Brian Haynes, R Evid Based Med 2006;11:162-164

Systems

Summaries

Synopses

Syntheses

Studies

>>>>>>

Aware Accepted Applicable Able Acted on Agreed Adhered to Unsound Research

Sound Research

7A

5S

--from bench to bed (B2B : 5S , 7A)

SR (2008) (2006) IV set U burn (2008) epinephrine (2005)

Contrast media reminding system Safe Timely

Daily

50 RCTs 2000 Medline New articles 6,000 biomedical articles

Surgery, Veterinary A board-certified specialty of VETERINARY

MEDICINE, requiring at least four years of special education, training, and practice of veterinary surgery after graduation from veterinary school. In the written, oral, and practical examinations candidates may choose either large or small animal surgery. (From AVMA Directory, 43d ed, p278)

Year introduced: 1991(1975)

Forest plot

Forest plot

The first use in print of the word "forest plot" may be 1996. Steff Lewis & Mike Clarke (June 2001). "Forest plots: trying to

see the wood and the trees". BMJ 322: 14791480.

The name refers to the forest of linesproduced.

http://en.wikipedia.org/wiki/File:Forestplot01.jpg

Cochrane Collaboration Logo

(meta-analysis of seven trials)

The Cochrane logo a review of a short, inexpensive course of corticosteroids given

to women about to give birth prematurely. Although corticosteroids are now routinely used to accelerate

fetal lung maturity in infants at risk of premature delivery, this practice was considered to be controversial in the early days ofthe Collaboration.

Seven small RCTs had been completed, but the results were conflicting.

Most of the studies did not show a statistically significant benefit from corticosteroid therapy.

When the studies were combined in a Cochrane review, however, it became clear that corticosteroid therapy has a positive overall effect in infants at risk of preterm delivery.

Systematic review

Meta-analysis ( ):

Systematic reviewvs.

Meta-analysis

Systematic Reviews to Support Evidence-Based Medicine:

How to Review and Apply Findings of Healthcare Research

Khalid S. Khan

Khalid S. Khan, Regina Kunz, Jos Kleijnen, & Gerd Antes. (2003). Systematic Reviews to Support Evidence-Based Medicine: How to Review and Apply Findings of Healthcare Research Royal Society of Medicine Press.

5 Distinct Areas of Activity within a Systematic Review

Development of a review question

Identification of research evidence

Selection of studies

Assessment of study quality

Data extraction and synthesis

(Khan KS, Ter Riet G, Glanville J, Sowden AJ, & Kleijnen J, 2001)

Development of a review question

Stay Hungry, Stay Foolish

Steve Jobs, 2005/06/12Stanford University

Universal Doubt :--- Rene Descartes 1596-1650

I think therefore I am. () Self-evident

IThink : doubt

: EBM Center 2007

Asking focused questions

Scenario: do I need to give perioperativeantimicrobial therapy when performing orthopedic surgery? Patient: the animals performed orthopedic surgery Intervention: perioperative antimicrobial therapy Comparison: giving perioperative antimicrobial

therapy or not Outcome: influence of infection rate

--, Evidence-based veterinary medicine, [presentation slides], 2011/1/11

Effect of perioperative prophylactic antimicrobial treatment in dogs undergoing elective orthopedic surgery.

DESIGN: Randomized, controlled, blinded, intention clinical trial. ANIMALS: Dogs of any breed, sex, or age

undergoing elective orthopedic surgery at a veterinary teaching hospital.

PROCEDURES: Dogs were randomly assigned to 1 of 3 groups: treatment with saline solution, treatment with potassium penicillin G, and treatment with cefazolin. Treatments were intended to be administered within 30 minutes prior to surgery; a second dose was administered if surgery lasted > 90 minutes. Dogs were monitored for 10 to 14 days after surgery for evidence of infection.

Whittem TL, Johnson AL, Smith CW, Schaeffer DJ, Coolman BR, Averill SM, Cooper TK, Merkin GR.Effect of perioperative prophylactic antimicrobial treatment in dogs undergoing elective orthopedic surgery.J Am Vet Med Assoc. 1999 Jul 15;215(2):212-6.

Effect of perioperative prophylactic antimicrobial treatment in dogs undergoing elective orthopedic surgery.

RESULTS: After the first 112 dogs were enrolled in the study, it was found that infection rate for control dogs (5/32 dogs) was significantly higher than the rate for dogs treated with antimicrobials (3/80 dogs). Therefore, no more dogs were enrolled in the study. A total of 126 dogs completed the study. Monte Carlo simulations indicated thatcompared with dogs that received antimicrobials prophylactically, dogs that received saline solution developed infections significantly more frequently. Difference in efficacy, however, was not observed between the 2 antimicrobial drugs used.

CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that perioperative antimicrobial prophylaxis decreased postoperative infection rate in dogs undergoing elective orthopedic surgery, compared with infection rate in control dogs. Cefazolin was not more efficacious than potassium penicillin G in these dogs

Whittem TL, Johnson AL, Smith CW, Schaeffer DJ, Coolman BR, Averill SM, Cooper TK, Merkin GR.Effect of perioperative prophylactic antimicrobial treatment in dogs undergoing elective orthopedic surgery.J Am Vet Med Assoc. 1999 Jul 15;215(2):212-6.

Identification of research evidence

EBM Steps

Answerable QuestionSearchAppraise

Apply Time 6 minutes

Systematic Review Steps

Answerable QuestionSearch ++++Appraise 2Synthesize

Apply Time 6 months

When systematic reviews are not availability clinicians need efficient

strategies for identifying relevant research

Paul Glasziou s lecture, 2006

Linda Ward, A survey of UK clinical librarianship: February 2004, Health Information and Libraries Journal, 22, pp.2634, 2005

800Cochrane Database of Systemic Review (CDSR)

!

: http://clc.nhri.org.tw/admin/clcmain1.aspx

/! 037-246166*36349

Searching the database 2 methods

using Free-text terms directly search PubMed bibliographic database using

the searchable PICO terms just identified

using MeSH terms MeSH thesaurus is a standardized dictionary of terms first search the MeSH thesaurus for MeSH terms

corresponding to the searchable PICO terms then search the bibliographic database using the

selected MeSH terms

47http://www.ncbi.nlm.nih.gov/pubmed

Finding the evidence

Scenario: A four-year-old Schnauzer has suffered from OU cataract and get blindness. The client is concerned that the recovery of vision after cataract extraction surgery. The clinical question: the recovery of vision after

cataract extraction surgery The type of question: prognosis The study design: Cohort study > case control > case

series

--, Evidence-based veterinary medicine, [presentation slides], 2011/1/11

Selection of studies

PRISMA statement

(Moher, 2009)

Assessment of study quality

Characteristics of included studies Table in RevMan 5

59

Cochrane Risk of Bias assessment

60

Data extraction and synthesis

Forest plot

Forest plot

Forest plot, a graph which shows

the results of the individual studies in the form of a point estimate of the treatment effect and its confidence interval

the weighted (pooled) average effect of all the study results

Sensitivity to sub-group analysis

Interpreting outcome heterogeneity

low (and negative) values indicate no, or small between-study heterogeneity

larger values show increasing heterogeneity

values of of 25%, 50% and 75% correspond to low, moderate and high levels of heterogeneity(Higgins et al 2003, BMJ)

Part II: , EBM

From trial, SR, EBM to form the knowledge translation.

Clinical trials

Clinical trials are conducted to allow safety and efficacy data to be collected for new drugs or devices.

http://en.wikipedia.org/wiki/Clinical_trial

(Shennong 3000 B.C. )

http://www.epochtimes.com/b5/1/9/4/c5053.htm

http://upload.wikimedia.org/wikipedia/commons/b/b6/Shennong.jpg

N of 1 trial An N of 1 trial is a clinical trial in which a single patient is the entire

trial, for example, a single case study. A trial in which randomallocation is used to determine the order in which an experimental and a control intervention are given to a patient is an N of 1 randomized controlled trial.

This type of study is only encountered sporadically in medical journals, because this type of design cannot definitively demonstrate causality, because different points in time are compared with one another. Moreover, the design is rather inefficient, since the results correspond with those from observation without randomization, placebo control or blinding. Even so, the N-of-1 trial is the ultimate form of verification in, for example, the individualization of treatment.

http://en.wikipedia.org/wiki/N_of_1_trial

:

On one occasion when a noble, who was the minister in power in his native State, sent him a present of some medicines, he received it respectfully, but said to the

messenger: Tell your Master I do not know the nature of the drugs; therefore I shall be afraid to use it.

--

Randomized controlled clinical trial

Ref:New Zealand Guidelines Group (NZGG). Handbook for the preparation of explicit evidence-based clinical practice guidelines, 2001 p44.

Who is he?

Archie Cochrane (1909-1988)

From 1 June, 1941 he spent 4 years as a prisoner of war (POW) at several camps in Crete, Greece and Germany.

His first, worst and most successful clinical trial

http://www.cardiff.ac.uk/insrv/libraries/scolar/archives/cochrane/warexperience.html

74 2003/07 531-534

The First Real Randomized Trial

Realization of selection bias problems with alternate allocation

Hill looked for opportunities to employ proper randomization

Pertussis vaccine trial; pilot in 1944; completed in 1950

Streptomycin for tuberculosis; initiated later; published in the BMJ in 1948

Bradford A. Hill, 1897-91

RCT

From: , :

, (2008). The Lancet - . ELSEVIER TAIWAN LLC. ISBN: 978-986- 01-0187-4 [: Kenneth F. Schulz, David A. Grimes.(2006). Handbook of Essential Concepts in Clinical Research. ELSEVIER Ltd.]

Sir Ronald Aylmer Fisher (1890-1962)

Anders Hald

Richard Dawkins

"Fisher introduced the randomization test, comparing the value of t or z actually obtained with the distribution of the t or z values when all possible random arrangements were imposed on the experimental data."

--Frank Yates & Kenneth Mather (1963) "Ronald Aylmer Fisher." Biographical Memoirs of Fellows of the Royal Society of London 9:91-120

1972Archie Cochrance RCTbias

1980David Sackett McMaster University

50Cochrane review groups

Oxford Center (May 2001)

(Levels of Evidence)

1.

2.

3.

4.

5.

Bob Phillips, et al. Oxford Centre for Evidence-based Medicine Levels of Evidence. 2001 [cited; Available from: http://www.cebm.net/index.aspx?o=1047.]

Why Cochrane Collaboration?

The Cochrane Collaboration is named in honor of Archie Cochrane, a British medical researcher who contributed greatly to the development of epidemiology as a science.

Professor Archibald Leman Cochrane, CBE FRCP FFCM, (1909 - 1988)

Cochrane 14 Centers

Cochrane Centers

1992McMaster

Gordon Guyatt

Evidence-Based Medicine Working Group.Evidence-based medicine.A new approach to teaching the practice of medicine.JAMA 1992;268:2420-5.

Trials vs. SR

(1) ?

Richy F, Bruyere O, Ethgen O, Cucherat M, Henrotin Y, Reginster JY.Structural and symptomatic efficacy of glucosamine and chondroitin in knee osteoarthritis: a comprehensive meta-analysis.Arch Intern Med. 2003 Jul 14;163(13):1514-22.

Richy F, Bruyere O, Ethgen O, Cucherat M, Henrotin Y, Reginster JY.Structural and symptomatic efficacy of glucosamine and chondroitin in knee osteoarthritis: a comprehensive meta-analysis.Arch Intern Med. 2003 Jul 14;163(13):1514-22.

Vlad SC, LaValley MP, McAlindon TE, Felson DT. Glucosamine for pain in osteoarthritis: why do trial results differ?Arthritis Rheum. 2007 Jul;56(7):2267-77.

Vlad SC, LaValley MP, McAlindon TE, Felson DT. Glucosamine for pain in osteoarthritis: why do trial results differ?Arthritis Rheum. 2007 Jul;56(7):2267-77.

Vlad SC, LaValley MP, McAlindon TE, Felson DT. Glucosamine for pain in osteoarthritis: why do trial results differ?Arthritis Rheum. 2007 Jul;56(7):2267-77.

Trials vs. SR

summary of the recommendations in the AAOS clinical practice guideline - 2009

Recommendation 12 We recommend glucosamine and/or

chondroitin sulfate or hydrochloride not be prescribed for patients with symptomatic OA of the knee.

Level of Evidence: I Grade of Recommendation: A

AHRQ offers new guides to OA treatment

2009 April

Trials vs. SR

(2) ?

Cochrane collaboration

. . . 2010-01-12

. . . 2010-01-12

. . . 2010-01-12

4

2010/1/26

Knowledge Translation (or KT)() describes either a structured process or the activity that results in scientifically researched evidencebeing used to improve the outcomes of professional practice.

http://en.wikipedia.org/wiki/Knowledge_translation

EBM the bridge between bench and bed

Knowledge Translation in Health Care: Moving from Evidence to

Practice Sharon Straus

Knowledge Translation in Health Care: Moving from Evidence to Practice. Sharon Straus (Editor), Jacqueline Tetroe (Editor), Ian D. Graham (Editor) ISBN: 978-1-4051-8106-8 May 2009, Wiley-Blackwell

Westfall JM, Mold J, Fagnan L. Practice-based research--"Blue Highways" on the NIH roadmap. JAMA. 2007 Jan 24;297(4):403-6.

(TEBMA)

2010/1/17-18 Dr. Edwin Chan

(Taiwan Evidence-Basded

Medicine Association, TEBMA) 2007815

http://www.tebma.org.tw

(:0960137058)

**

Thank You !!!

@ clifchen@tmu.edu.tw

Part I: (systematic review, SR)SR DailyForest plotCochrane Collaboration LogoThe Cochrane logoSystematic reviewMeta-analysis ( ):Systematic reviewvs.Meta-analysisSystematic Reviews to Support Evidence-Based Medicine: How to Review and Apply Findings of Healthcare Research 5 Distinct Areas of Activity within a Systematic ReviewDevelopment of a review questionUniversal Doubt : --- Rene Descartes 1596-1650 Asking focused questionsEffect of perioperative prophylactic antimicrobial treatment in dogs undergoing elective orthopedic surgery.Effect of perioperative prophylactic antimicrobial treatment in dogs undergoing elective orthopedic surgery.Identification of research evidenceWhen systematic reviews are not availability clinicians need efficient strategies for identifying relevant researchSearching the database 2 methodsFinding the evidenceSelection of studiesPRISMA statementAssessment of study qualityCharacteristics of included studies Table in RevMan 5Cochrane Risk of Bias assessmentData extraction and synthesisForest plotForest plotInterpreting outcome heterogeneityPart II: , EBMClinical trials(Shennong 3000 B.C. ) N of 1 trial :Randomized controlled clinical trialWho is he?Archie Cochrane (1909-1988)The First Real Randomized TrialBradford A. Hill, 1897-91RCTSir Ronald Aylmer Fisher (1890-1962)Oxford Center (May 2001)Trials vs. SRTrials vs. SRsummary of the recommendations in the AAOS clinical practice guideline - 2009AHRQ offers new guides to OA treatment Trials vs. SR 4EBM the bridge between bench and bedKnowledge Translation in Health Care: Moving from Evidence to Practice(Taiwan Evidence-Basded Medicine Association, TEBMA) 2007815 Thank You !!!