临床流行病学：预后评价和循证医学

预后评价和循证医学预后评价和循证医学循证医学循证医学(Evidence-Based Medicine)循证医学与临床实践循证医学与临床实践预后的临床问题预后的临床问题预后的定义预后的定义预后问题的三要素预后问题的三要素预后研究的意义预后研究的意义有关预后文献分析步骤有关预后文献分析步骤文献结果的真实性文献结果的真实性(1)预后研究中的关键问题预后研究中的关键问题疾病的自然史疾病的自然史临床病程临床病程文献结果的真实性文献结果的真实性(2)失访的处理失访的处理文献结果的真实性文献结果的真实性(3)文献结果的真实性文献结果的真实性(4)预后因素预后因素预后因素分类预后因素分类预后因素研究的统计学方法预后因素研究的统计学方法预后研究中的常见偏倚预后研究中的常见偏倚预后研究中偏倚的处理方法预后研究中偏倚的处理方法研究的结果是什么研究的结果是什么(1)疾病预后的评定指标疾病预后的评定指标生存率分析生存率分析(1)四种情况的四种情况的5年生存率曲线年生存率曲线生存率分析生存率分析(2)失访的处理失访的处理Kaplan-Meier生存曲线生存曲线TIME140120100806040200Cum Survival1.0.8.6.4.20.0GROUP 2 1 0研究的结果是什么研究的结果是什么(2)可信区间可信区间结果是否有助于处理我的病人结果是否有助于处理我的病人(1)结果是否有助于处理我的病人结果是否有助于处理我的病人(2)实践实践EBM的步骤的步骤Evidence PyramidEvidence Based Decision Making LevelsEBMEvidence Based Decision Making LevelsEBM有关预后文献分析步骤有关预后文献分析步骤临床问题举例临床问题举例文献评价文献评价文献评价文献评价临床应用临床应用Subclinical HyperthyroidismCase PresentationCase PresentationCase PresentationClinical QuestionCommon Signs/Symptoms Evidence-based Research?Toft, A.D. New England Journal of Medicine, 2001; 345(7):512516. Shrier, D.K., Burman, K.D. American Family Physician, 2002; 65(3). Short/Long-term EffectsBiondi, B., et al. Journal of Clinical Endocrinology and Metabolism, 2000; 85(12):4701-4705.Shrier, D.K., Burman, K.D. American Family Physician, 2002; 65(3). Adverse EffectsBiondi, B., et al. Journal of Clinical Endocrinology and Metabolism, 2000; 85(12):4701-4705.Kalmijn, S., Mehta, K.M., et al. Clinical Endocrinology (Oxf), 2000; 53: 733-737.Journal ArticleSawin, C.T., Geller, A., et al. New England Journal of Medicine, 1994; 331(19): 1249-1252.ResultsSawin, C.T., Geller, A., et al. New England Journal of Medicine, 1994; 331(19): 1249-1252.Journal ArticleBiondi, B., et al. Journal of Clinical Endocrinology and Metabolism, 2000; 85(12):4701-4705.ResultsBiondi, B., et al. Journal of Clinical Endocrinology and Metabolism, 2000; 85(12):4701-4705.1. Multinodular goiter, solitary autonomous nodule; no antithyroid Abs; significant difference in free T3 and free T4 between groups2. Higher mean SRS score in patients as well as lower SF-36 scores (r = -0.84, p = 0.008)3. No ECG abnormality; Holter showed higher average HR (p 0.001) and higher prevalence of APCs in patients (p = ns)4. Doppler echo showed increased PWT and IVST in patients as well as higher indices of LV systolic functionConclusions Patients were affected by endogenous subclinical hyperthyroidism as evidenced by increased symptoms and impaired quality of life. Cardiac morphology and function affected by increased heart rate, LV mass, enhanced LV function and impaired diastolic filling Untreated endogenous subclinical hyperthyroidism may have untoward effects in young and middle-aged so consider early treatment.Biondi, B., et al. Journal of Clinical Endocrinology and Metabolism, 2000; 85(12):4701-4705.Subclinical HyperthyroidismPrevention of atrial fibrillation and osteoporosis are the main potential benefits of treating subclinical hyperthyroidism.Treatment options include:- Beta-blockers- Antithyroid medications- Radioactive iodine (131I)- Surgery- Close clinical follow-upThe Answer(To My Clinical Question)Critical Appraisal of the Literature:Patient prognosis: Scenario:Critical Appraisal of the Literature:Patient prognosis: Scenario: Critical Appraisal of the Literature:Patient prognosis: Scenario: SearchCRITICAL APPRAISAL OF THE BIOMEDICAL LITERATUREPROGNOSIS Thank you。