پاورپوینت کامل Evidence Based Medicine 85 اسلاید در PowerPoint

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پاورپوینت کامل Evidence Based Medicine 85 اسلاید در PowerPoint

اسلاید ۴: What is evidence based medicine (EBM)“the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” The integration of individual clinical expertise with the best available external clinical evidence from systematic research. Initially proposed by Dr. David Sackett and colleagues at McMasters University in Ontario, Canada.Sackett DL, et al. Evidence-Based Medicine: What it is and what it isn’t. BMJ 1996; 312:71-2.

اسلاید ۵: Adapted from: Sackett D.L., Rosenberg M.C., Gray J.A., Haynes R.B., Richardson W.S. (1996). Evidence based medicine: what it is and what it isnt. BMJ, 312, 71-72.

اسلاید ۶: Why is EBM importantNew types of evidence are being generated which can create changes in the way patients are treatedAlthough evidence is needed on a daily basis, usually physicians don’t get it.How much is actually being applied to patient carelack of time out-of-date textbooks, and the disorganization of the up-to-date journals6 Covell DG, Uman GC, Manning PR: Information needs in office practice: Are they being met Ann Intern Med 1985;103:596-9.

اسلاید ۷: Why is EBM importantUp-to-date knowledge and clinical performance can deteriorate with timeThere is a statistically and clinically significant negative correlation between a physician’s knowledge of up to date care and the years that have elapsed since graduation from medical school. Ramsey PG, Carline JD, Inui TS et al: Changes over time in the knowledge base of practicing internists. JAMA 1991;266:1103-7.Davis DA, Thompson MA, Oxman AD, Haynes RB: Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-5. Traditional continuing medical education programs have not been shown to improve clinical performanceSystematic reviews of the relevant randomized trials have shown that traditional, instructional CME fails to modify clinical performance and is ineffective in improving the health outcomes of patients.

اسلاید ۸: Why is EBM importantKnowledge translation – increasing the uptake of the best available evidence into practice – has always been a challengeScurvy: use of citrus was proven to prevent and cure scurvy in 1754, but it was almost 50 years after the data was published before lemon juice was added to British shipsAdditive to diet (n=2 in each groupObserved effectQuart of ciderMinor improvementUnspecified elixir t.d.sNo changeSeawaterNo changeGarlic, mustard and horseradishNo changeSpoonfuls of vinegarNo changeTwo oranges and a lemonDramatic recoveryTable 1. Lind’s study on scurvy:1747The James Lind Library. Available from http://ind/. Accessed 26 June 2008.

اسلاید ۹: Puerperal fever mortality rates for the First and Second Clinic at the Vienna General Hospital 1841-1846. The top line is the First Clinic, bottom line Second Clinic.

اسلاید ۱۰: Why is EBM importantPeriodCharacteristics of periodNo. deliveriesNo. maternal deathsMaternal deaths/1000 deliveries1784-1822No routine post-mortems71,395 89712.51823-1838Routine post-mortems65,0353,74557.61839-1847Clinic arrangements changed First clinic: doctors and students Second clinic: midwives 20,204 17,791 1,989 691 90.2 33.81848-1859Hand-washing introduced First clinic Second clinic 47,938 40,770 1,712 1,248 35.7 30.6Chloride of lime: In 1846 Ignatz Semmelweis attributed puerperal fever to an infection carried by obstetricians. Despite reducing maternal mortality from 18 to 1.2% by hand-washing in chloride of lime, his findings were rejected by the medical society of Vienna. It would take until the 1890’s before it was accepted that microorganisms can cause disease.Table 2. Mortality rates and characteristic of obstetrics clinics in Vienna 1784-1859

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اسلاید ۱۲: EBM processes can help with dissemination and adoption

اسلاید ۱۳: Complementary/Alternative MedicineComplementary and alternative medicine is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.National Center for Complementary and Alternative Medicine. Understanding complementary and alternative medicine. Available at:http://nccam.nih.gov/health/.While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies–such as:Are these therapies safe Do these therapies work for the diseases or medical conditions for which they are used

اسلاید ۱۴: Are Complimentary and Alternative Medicine Interchangeable TermsComplementary medicine is used together with conventional medicine. Example: Using aromatherapy to help lessen a patients discomfort following surgery.National Center for Complementary and Alternative Medicine. Understanding complementary and alternative medicine. Available at: http://nccam.nih.gov/health/.Alternative medicine is used in place of conventional medicine. Example: When Suzanne Somers rejected chemotherapy in favor of a drug called Iscador (uses extracts of Mistletoe) to treat her breast cancer.

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اسلاید ۱۶: Family: Woman Died After Choosing Herbal Medicine Over Cancer SurgeryStudies estimate that 60 percent of cancer patients try unconventional remedies and about 40 percent take vitamin or dietary supplementsNone has turned out to be a cure, although some show promise for easing symptoms. Touch therapies, mind-body approaches and acupuncture may reduce stress and relieve pain, nausea, dry mouth and possibly hot flashes, and are recommended by many top cancer experts. A recent study found that ginger capsules eased nausea if started days before chemotherapy.One quarter of supplements tested by an independent company over the last decade have had some sort of problem. Some contained contaminants. Others had contents that did not match label claims. Some had ingredients that exceeded safe limits. Some contained real drugs masquerading as natural supplements.

اسلاید ۱۷: $۲.۵ billion spent, no alternative cures found Big, government-funded studies show most work no better than placebosThe Associated Pressupdated 11:15 a.m. CT, Wed., June 10, 20DA, Md. – Ten years ago the government set out to test herbal and other alternative health remedies to find the ones that work. After spending $2.5 billion, the disappointing answer seems to be that almost none of them do.Echinacea for colds. Ginkgo biloba for memory. Glucosamine and chondroitin for arthritis. Black cohosh for menopausal hot flashes. Saw palmetto for prostate problems. Shark cartilage for cancer. All proved no better than dummy pills in big studies funded by the National Center for Complementary and Alternative Medicine. The lone exception: ginger capsules may help chemotherapy nausea.As for therapies, acupuncture has been shown to help certain conditions, and yoga, massage, meditation and other relaxation methods may relieve symptoms like pain, aپاورپوینت کامل Evidence Based Medicine 85 اسلاید در PowerPointiety and fatigue.

اسلاید ۱۸: Major Types of Complementary and Alternative MedicineAlternative medicine systems: Built upon complete systems of theory and practice. Examples: homeopathic medicine, naturopathic medicine, traditional Chinese medicine, Ayurveda.National Center for Complementary and Alternative Medicine. Understanding complementary and alternative medicine. Available at: http://nccam.nih.gov/health/.Mind-body interventions: Uses a variety of techniques designed to enhance the minds capacity to affect bodily function and symptoms. Some techniques that were considered CAM in the past have become mainstream (patient support groups and cognitive-behavioral therapy). Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance.

اسلاید ۱۹: Major Types of Complementary and Alternative Medicine cont.Biologically Based Therapies: Use substances found in nature (herbs, foods, and vitamins). Example: shark cartilage to treat cancer.National Center for Complementary and Alternative Medicine. Understanding complementary and alternative medicine. Available at: http://nccam.nih.gov/health/.Examples of dietary supplements that have been incorporated into mainstream medicine:Folic acid to prevent birth defects Regimen of vitamins and zinc to slow the progression age-related macular degeneration (AMD).

اسلاید ۲۰: Major Types of Complementary and Alternative Medicine cont.Manipulative or Body-Based Methods: Based on manipulation and/or movement of one or more parts of the body. Examples: chiropractic or osteopathic manipulation, massage.National Center for Complementary and Alternative Medicine. Understanding complementary and alternative medicine. Available at: http://nccam.nih.gov/health/.Energy Therapies: Involve the use of energy fields.Biofield therapies: intended to affect energy fields that purportedly surround and penetrate the human body (the existence of such fields has not yet been scientifically proven). Examples: qi gong, Reiki, Therapeutic Touch. Bioelectromagnetic-based therapies: unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.

اسلاید ۲۱: NCCAMNational Center for Complementary and Alternative MedicinePart of NIH, established in 1998Dedicated to exploring complementary and alternative healing practices in the context of rigorous science, training complementary and alternative medicine (CAM) researchers, and disseminating authoritative information to the public and professionals.NCCAM Web site (nccam.nih.gov): publications, information for researchers, frequently asked questions, and links to other CAM-related resources.

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اسلاید ۳۲: What is EBM“Evidenced-based medicine is the concept of formalizing the scientific approach to the practice of medicine for identification of “evidence” to support our clinical decisions. It requires an understanding of critical appraisal and the basic epidemiologic principles of study design, point estimates, relative risk, odds ratios, confidence intervals, bias, and confounding. By using this information, clinicians can categorize evidence, assess causality, and make evidence-based recommendations. Evidence-based medicine allows analysis of complicated material so that we can make the best possible clinical decisions for the populations we serve.”Williams JK. Understanding evidence-based medicine: a primer. Am J Obstet Gynecol 2001:185-275-278.

اسلاید ۳۳: Developing the clinical questionStep 1: Formulate the clinical issue into a searchable, answerable question.Step 2: Distinguish what type of question you may have.BackgroundForegroundExperience with Condition

اسلاید ۳۴: Background questionsBackground questions ask for general information about a condition or thing.A question root (who, what, when, etc) combined with a verb.Background questions are typically answered by textbooks. What microbial organisms can cause community-acquired pneumonia

اسلاید ۳۵: Foreground questionsForeground questions ask for specific knowledge about a specific patient with a specific condition.Foreground questions are typically answered by databases that access the research literatureIs St. John’s Wort effective in relieving the symptoms of post-partum depression

اسلاید ۳۶: Developing the questionForeground questions usually have four components.P = Patient populationI = InterventionC = ComparisonO = Outcome

اسلاید ۳۷: Patient population/diseaseThe patient population or disease of interest – age – gender – ethnicity – with certain disorder (e.g., hepatitis)InterventionThe intervention or range of interventions of interest – Exposure to disease – Prognostic factor A – Risk behavior (e.g., smoking)ComparisonWhat you want to compare the intervention against – No disease – Placebo or no intervention/therapy – Prognostic factor B – Absence of risk factor (e.g., non-smoking)OutcomeOutcome of interest – Risk of disease – Accuracy of diagnosis – Rate of occurrence of adverse outcome (e.g., death)PICO: Components of an answerable, searchable questionMelnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare : A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins.

اسلاید ۳۸: In patient with [Patient/ Problem]does[Intervention]or[Comparison, if any]affect[Outcome]In patients with chronic pain, does the use of progressive muscle relaxation lead to a lessening of pain In patients with significant anterior or posterior vaginal wall prolapse, do vaginal cones help In patients with moderate depression, is St. John’s Wort vs. traditional SSRI’s effective in relieving symptoms with fewer adverse effects

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