Answering Clinical Questions at the Answering Clinical Questions at the Point of Care

鄭如雅 Crystal Chengccheng@uptodate.comg pTel : +886-4-22233493Mobile : +886-923575668

OutlineOutl e

About UpToDate UpToDate簡介

Evidence Grading 證據等級Evidence Grading 證據等級

How to Search 如何使用 UpToDate

Q&A 問題與討論

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UpToDateUp o ate

UpToDate is a Clinical decision support system that helps clinicians UpToDate is a Clinical decision support system that helps clinicians throughout the world provide the best patient care

We use the best available current evidence to answer clinical We use the best available current evidence to answer clinical questions, quickly and easily at the point of care

This saves clinicians time improves patient outcomes and lowers This saves clinicians time, improves patient outcomes and lowers health care costs

UpToDate 設計來協助醫師們進行診療上的判斷和決策，目前UpToDate 設計來協助醫師們進行診療上的判斷和決策 目前UpToDate 收錄的 Topic Reviews，全部皆由 UpToDate 的主編和超過5500 位的醫師作者們執筆所撰寫，是由作者們瀏覽 peer-reviewed 的期刊再加上專業 經驗和意見而成的 文獻中附有圖片 包括圖表的期刊再加上專業，經驗和意見而成的．文獻中附有圖片，包括圖表，X 光片，相片，影像文件等，及 MEDLINE 的引用文獻摘要．並提供Lexi-Compe 的藥物信息並可以執行藥物交互作用．

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Evidence is derived from a number of sources………………including but not limitedJournals: 440+ peer reviewed journals 同儕審查期刊Journals: 440+ peer reviewed journals 同儕審查期刊

Databases:電子資鴻

MEDLINE Th C h D b Cli i l MEDLINE, The Cochrane Database, Clinical Evidence and ACP Journal Club

G id li 臨床指引Guidelines 臨床指引Clinical trials 臨床試驗

FDA, CDC, NIH

Proceedings 國家以及國際的會議Proceedings 國家以及國際的會議

Clinical experiences and observations

作者的經驗和觀察作者的經驗和觀察4

Quick Facts about UpToDateQu c acts about Up o ate

Topic reviews 全文型的資料Patient Information 衛教資料Patient Information 衛教資料

Drug Information 藥物資料

Written by Physicians for Physicians

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Quick Facts about UpToDateQu c acts about Up o ate

5 500+ world-renowned physician authors 5,500+ world-renowned physician authors (international) 作者數量

8 300+ clinical topic in 17 specialties 包含科别8,300+ clinical topic in 17 specialties 包含科别

4,600+ unique drug entries in adult, pediatrics, international and natural drugs (Lexi-Comp) international and natural drugs (Lexi Comp)

藥物資訊

包含圖表21,000+ graphics 包含圖表

385,000+ references (Medline) 包含引用文獻

Updated every 4 months (March, July, November)

一年更新三次年更新三次6

SpecialtiesSpec alt es

• Adult and Pediatric Emergency Medicine 急診• Adult Primary Care & Internal Medicine 一般內科• Allergy and Immunology 過敏免疫• Cardiovascular Medicine 心臟內科• Endocrinology & Diabetes 內分泌及糖尿病• Family Medicine 家庭醫學• Gastroenterology & Hepatology 肝膽腸胃科gy p gy• Hematology 血液科• Hospital Medicine 醫學醫學• Infectious Diseases 感染科• Nephrology & Hypertension 腎臟科及高血壓• Neurology 神經內科• Obstetrics, Gynecology & Women’s Health 婦產科Obstetrics, Gynecology & Women s Health 婦產科• Oncology 腫瘤科• Pediatrics 小兒科• Pulmonary Critical Care & Sleep Medicine 胸腔醫學及重症醫學Pulmonary, Critical Care & Sleep Medicine 胸腔醫學及重症醫學• Rheumatology 風濕科7

Specialties in DevelopmentSpec alt es evelop e t

• Dermatology 皮膚科精神病學• Psychiatry 精神病學

• Surgery 外科Surgery 外科

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Evidence Grading 證據等級Evidence Grading 證據等級

In 2001, we began a collaboration with Gordon Guyatt, a world leader in EBM, and his colleagues in th i t ti l GRADE ll b ti t i l t the international GRADE collaborative to implement a grading system for recommendations

U T D t d ifi t t t d i UpToDate grades specific treatment and screening recommendations

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Evidence Grading 證據等級Evidence Grading 證據等級RECOMMENDATION GRADES 醫囑的強度

Grade 1Strong Recommendation Benefits clearly outweigh the risks and

burdens (or vice versa) for most, if not all, patients “We recommend…”

Grade 2Weaker Recommendation Benefits and risks closely balanced and/or

uncertain “We suggest…”

證據的品質EVIDENCE GRADES 證據的品質

Grade A High Quality EvidenceConsistent evidence from randomized trials or overwhelming evidence of some Grade A High Quality Evidence trials, or overwhelming evidence of some other form

Grade B Moderate Quality Evidence Evidence from randomized trials with important limitations or very strong Grade B Moderate Quality Evidence important limitations, or very strong evidence of some other form

Evidence from observational studies,

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Grade C Low Quality Evidence,

unsystematic clinical observations, or from randomized trials with serious flaws

How to Search 如何使用 UpToDateHow to Search 如何使用 UpToDate

N S h 單一檢索方式New Search 單一檢索方式

Search display results topic review output

檢索 瀏覽檢索結果 如何使用内容 輸出

Others 其它功能Others 其它功能Evidence grading 如何找到證據等級

RECOMMENDATIONSRECOMMENDATIONS

97 Calculators 醫學試算表Drug Interactions 藥物交互作用Drug Interactions 藥物交互作用ECG Test 心電圖自我測驗Movies 影像檔

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How to use UpToDate based on a Cli i l iClinical scenario

A 50 year old woman is obese (BMI 32) and has A 50 year old woman is obese (BMI=32) and has hypertension. She has not achieved weight loss despite counseling for diet and lifestyle changes.

h h b d f h lWhat is the best medication for pharmacologic management of her obesity.

有一位 歲的女性 是 而且有高壓血 她透過節食有一位50歲的女性，BMI是32, 而且有高壓血 ; 她透過節食和改變生活習慣來減肥, 但是失敗了 ; 現在希望可以直接吃藥來達到減肥的目的; 什麼藥物可以讓她減肥又不會影響藥來達到減肥的目的; 什麼藥物可以讓她減肥又不會影響到她的高血壓的症狀呢 ?

Keyword: y

Obesity drug

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Q&A

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How to use UpToDate

鄭如雅

ccheng@uptodate.com

OutlineOutline

• About UpToDate

• How to Search

• Q & A

Ab t U T D tAbout UpToDate

Synthesizes the medical literature, incorporates the latest evidence andincorporates the latest evidence, and provides specific recommendations

for patient care

Evidence is derived from a number ofEvidence is derived from a number of Sources

J l 440 i d j l• Journals: 440+ peer viewed journals• Databases:

MEDLINE The Cochrane Database Clinical– MEDLINE, The Cochrane Database, Clinical Evidence and ACP Journal Club

• GuidelinesGuidelines• Clinical trials

– FDA, CDC, NIH, ,• Proceedings• Clinical experience and observations

Including but not limitedg

The editorial processThe editorial processLeading and Evidence Based Literature and Resources

Read ..... Analyze ..... Summarize .....

..... Synthesize .....

..... Expert Comments ..... pe t Co e ts

..... Expert Opinion .....

..... Recommendations .....

..... Grade the Evidence .....

..... Editorial Peer Review .....

UpToDate Topic Review

Quick Facts about UpToDateQuick Facts about UpToDate

• Topic reviews

• Patient Information

• Drug Information – Lexi-Comp

Quick Facts about UpToDateQuick Facts about UpToDate

5 500+ ld d h i i th (i t ti l)• 5,500+ world-renowned physician authors (international)

• 7,775 clinical topics in 17 specialties, p p

• 4,619 unique drug entries in adult, pediatrics, international, and natural drugs (Lexi-Comp)and natural drugs (Lexi Comp)

• 24,637 graphics

• 262,209 references (Medline)

• Update every 4 months (March, July, November)

SpecialtiesSpecialties• Adult and Pediatric Emergency Medicine • Dermatology (developing)• Adult Primary Care & Internal Medicine • Psychiatry (developing)Adult Primary Care & Internal Medicine Psychiatry (developing)• Allergy and Immunology • Surgery (developing)• Cardiovascular Medicine

E d i l & Di b t• Endocrinology & Diabetes• Family Medicine • Gastroenterology & Hepatologygy p gy• Hematology• Hospital Medicine New !!• Infectious Diseases• Infectious Diseases• Nephrology & Hypertension• Neurology• Obstetrics , Gynecology & Women’s Health• Oncology • PediatricsPediatrics• Pulmonary, Critical Care & Sleep Medicine• Rheumatology

To Access UpToDateTo Access UpToDate

• Please go to library homepage

• Just “Accept” the license agreement and you are brought to the search page, ready for your use; within a few secondswithin a few seconds

How to Search

How to SearchHow to Search

N S h• New Search– search display result output

• Others– Patient Information– What’s new– Calculators

E id di– Evidence grading• RECOMMENDATIONS

– Drug interactionsDrug interactions– ECG Test– Movies

How to use UpToDate based on aHow to use UpToDate based on a Clinical Scenario

• A 50 year old woman is obese (BMI=32) and has hypertension. She has not achieved weight loss despite counseling for diet and lifestyle changesdespite counseling for diet and lifestyle changes. What is the best medication for pharmacologic management of her obesityg y

• Keyword :Keyword : – obesity drugs

What’s New

Calculators

Patient Information

Calculators

此為主畫面除此以外另有三個頁面可以選點Patient Info-Patient Info

-What’s New-Calculators

關鍵字可以是關鍵字可以是-病名, 藥名, 症狀-大小寫皆可-可同時輸入二個字以上可同時輸入二個字以上-接受布林邏輯裡的 and 以及 or-系統亦提供拼錯檢查單複數不會影響檢索結果-單複數不會影響檢索結果

我們以obesity drug 來做查詢我們以obesity drug 來做查詢

當我們把關鍵字鍵入後系統會跳出相關的詞以供選擇系統會跳出相關的詞以供選擇

輸入完畢直接選點 Go

此為檢索結果另外有三個選項可以改變檢索結果的順序-Prioritize adult topics-Prioritize pediatric topicsPrioritize pediatric topics-Prioritize patient topics

可以預覽文章的 Outline-只要滑鼠移到文章篇名的上面，即可在右邊出現該篇文章的outline-若要進入本文，直接點選篇名-若只針對有興趣的段落，可直接點選右邊段落的裡的文字可直接點選右邊段落的裡的文字

建議：-This topic last update 這篇文章被更新的日期

這個議題的簡介-Introduction 這個議題的簡介-Recommendations 提供及時的答案

Drug information : 藥物資訊由 Lexi-Comp 提供，若想要p得到更詳細的資料， 可以點選具有超連結的藥名

此為另開一視窗此為另開一視窗以供瀏覽

-Reference 參考書目

圖表部份點選後則另開啟一個視窗以供瀏覽

- Export TO PowerPoint 直接將圖表轉入 PowerPointPrint- Print

- Email- 亦可滑鼠移到圖片上方, 按滑鼠右鍵, 選擇”複製”

OutputOutputPrint, Email, Save

Print-Print若要列印請選擇此功能可以完整的列出整篇文章包括圖表在內 (若文章有附)包括圖表在內 (若文章有附)-Email可以 email 文章內容不包括圖表在內不包括圖表在內

Print-Print若要列印請選擇此功能可以完整的列出整篇文章包括圖表在內 (若文章有附)包括圖表在內 (若文章有附)-Email可以 email 文章內容不包括圖表在內不包括圖表在內

cc

-星號欄位必填

ccheng@uptodate.com

-Your name 為寄件人的名字-Your e-mail 為寄件人的帳號-E-mail address of recipient

ccheng@uptodate.comp

為收件人的帳號-填寫完畢後，點選 Send

Patient Information

新增 Basic 等級的 Patient Information特色是 : 頁數 1-3 頁特色是 : 頁數 1 3 頁

較多圖表用 5-6 年級的英文程度來撰寫

What’s New

提供各科別的新訊為重點式的說明

Calculators

輸入身高和體重切換成我們常用的

輸入完畢後BMI值就呈現出來切換成我們常用的

單位 (公分和公斤)BMI值就呈現出來

Evidence Grading

Evidence Grading – UTD GRADEEvidence Grading UTD GRADERECOMMENDATION GRADES

St R d ti B fit l l t i h th i k dGrade 1

Strong Recommendation Benefits clearly outweigh the risks and burdens (or vice versa) for most, if not all, patients “We recommend…”

W k R d tiGrade 2

Weaker Recommendation Benefits and risks closely balanced and/or uncertain “We suggest…”

EVIDENCE GRADESG

Grade A High Quality EvidenceConsistent evidence from randomized trials, or overwhelming evidence of some other formo

Grade B Moderate Quality Evidence Evidence from randomized trials with important limitations, or very strong evidence of some other formevidence of some other form

Grade C Low Quality EvidenceEvidence from observational studies, unsystematic clinical observations, or from randomized trials with serious flaws

會放在特定的段落 : Recommendations

-點選 Evidence Grading 的超連結會有說明的視窗出現-會有說明的視窗出現

Others:Drug Interactions

ECGCGMovies

FeedbackFeedback

Drug Interactions

-提供二種以上的藥物執行藥物交互作用-目前以美國藥品為主目前以美國藥品為主-來源 : Lexi-Comp

一次輸入一種藥名-一次輸入一種藥名-可輸入多種藥品-以以下藥品為例aspiringrape seedlasixolistat

-輸入完畢-Analyze

-Risk rating 藥物交互作用的說明-點選超連結有藥物交互作結果的說明

若想知道單一藥品已知藥物交互作用的種類若想知道單一藥品已知藥物交互作用的種類輸入藥名後再直接點選藥名即會出現

ECG test

-關鍵字 : ecg test -檢索結果第一至第三個為 ECG test檢索結果第一至第三個為 ECG test分為初級 Basic，中級 Intermediate，高級 Advanced

Movies in Graphics

-會依據文章內容所提及部份輔以圖表做說明-圖表的大標題為 : Graphics圖表的大標題為 : Graphics-之下再細分屬性，例如 echocardiograms, table, figure

為影像檔-Movies 為影像檔-播放的軟體為：Apple Quick Time此軟體為免費下載

-系統會先偵測電腦有無安裝 Apple Quick Time有 : 會出現以下畫面無 : 會出現請至網頁下載並安裝 Apple Quick Time 提示畫面無 : 會出現請至網頁下載並安裝 Apple Quick Time 提示畫面

-右邊為左邊心臟的定格，再加上文字說明為左邊心臟的定格 再加上文字說明-左邊為影像檔 ，會跳動並自動重複播放

Feedback

-歡迎並感謝給予任何意見-Email內容直接至美國主編群，並由主編群直接回覆Email內容直接至美國主編群 並由主編群直接回覆

Q & A

Thank you for your attention