循证医学在胰腺病临床教学中的应用

循证医学（evidence—based mdeicine，EBM）是近年来国际临床医学领域中迅速兴起的一门新型学科，也是医学界倡导的学科发展方向之一。自20世纪80年代以来，临床试验研究尤其是大样本随机对照试验的异常活跃，为临床实践提供了大量极具有价值的证据，改变了许多传统的医学观念和认识，临床医学模式发生了深刻的变化，从以经验和推论为基础的经验医学转变为以随机对照研究（randomized clinicaltrial，RCT）、系统性评价和荟萃（Meta）分析提供的临床证据为基础的新的医学模式，即循证医学。循证医学的定义是：慎重、准确和明智地应用目前可获得的最佳研究证据，同时结合临床医师个人的专业技能和长期临床经验，考虑患的价值观和意愿，完善地将三结合在一起，制定具体的治疗方案。其核心思想是在医疗决策中将临床证据、个人经验与患的实际情况和意愿三结合。而临床医疗模式的改变也决定了临床医学教育的目标、体系、内容和方法的改变．在临床医学教育中引进并形成循证医学教育模式是循证医学发展的必然要求。     

循证医学在胰腺病临床教学中的应用

循证医学(evidence-based mdeicine, EBM)是近年来国际临床医学领域中迅速兴起的一门新型学科,也是医学界倡导的学科发展方向之一.自20世纪80年代以来,临床试验研究尤其是大样本随机对照试验的异常活跃,为临床实践提供了大量极具有价值的证据,改变了许多传统的医学观念和认识,临床医学模式发生了深刻的变化,从以经验和推论为基础的经验医学转变为以随机对照研究(randomized clinical trial, RCT)、系统性评价和荟萃(Meta)分析提供的临床证据为基础的新的医学模式,即循证医学.循证医学的定义是:慎重、准确和明智地应用目前可获得的最佳研究证据,同时结合临床医师个人的专业技能和长期临床经验,考虑患者的价值观和意愿,完善地将三者结合在一起,制定具体的治疗方案.其核心思想是在医疗决策中将临床证据、个人经验与患者的实际情况和意愿三者结合[1].     

学习循证医学指导呼吸疾病的临床研究

循证医学（evidence based medicine,EBM）是遵循科学证据的一种医学新模式。它的创立是临床医学发展的必然趋势。近年来人类疾病谱发生变化、信息与网络的迅速发展、参考书和医学期刊的时间滞后性及缺乏大规模随机对照试验（random control trial,RCT）作为验证等缺陷,以及经济学发展要求分析成本和效益,医疗费用增长的压力,医疗保险业的兴起,同类药品的多样性,新的临床科研方法的兴起,病人对自己疾病的关心和预后的评价等有力地促进了循证医学的发展。名临床流行病学家,EBM创始人之一David Sackeu,在EBM的原有概念上,将其定义补充为“慎重（conscientious）、准确（explicit）和明智地（judicious）应用当前所能获得的最好的研究证据,结合医生本人专业技能和多年临床经验,考虑患的价值和愿望,将三完美地结合所制定出患的处理措施。”EBM与传统医学的主要差异是指导临床实践的设想不同（见表1）,传统医学以个人经验为主,医生根据自己的实践经验、高年资医师的指导,采用教科书和医学期刊上零散的报告为依据来处理患,其结果是：一些真正有效的疗法由于不为众所了解而长期未被临床应用,一些实践无效甚至有害的疗法从理论上推断可能有效而长期地被广泛使用。循证医学既重视个人的临床经验,又强调采用现代的、最好的研究证据,两缺一不可;这种研究的依据主要强调临床、多中心研究的结果和患的预后。[第一段]     

循证医学与临床实践:概念、问题与进展

循证医学（EBM）自1992年问世以来发挥了重要的作用，促进了医学发展，转换了临床医学模式，澄清过去许多未能明确的问题。本文对循证医学形成背景、发展与目的；高血压治疗进展与EBM；评价证据和实施循证医学；循证医学临床实践的进展EBM规范性模式；影响循证医学实践的因素（如临床l状态及环境、患者意愿与行为、研究证据、临床专业技能）等进行了介绍，为正确理解和实施EBM，发挥其应有作用提供参考。     

大样本随机临床试验与循证医学

近二十年来,国际临床医疗模式发生了重大变化,由过去以经验为基础的医疗模式逐渐转变为以证据为基础的医疗模式。以证据为基础的医疗模式也称为循证医学或求证医学（ｅｖｉｄｅｎｃｅｂａｓｅｄｍｅｄｉｃｉｎｅ）。循证医学要求客观公正地评估某种治疗药物对患者生活质量的远期影响和生存率的影响。评估某种治疗药物好坏的标准有若干条,但最主要的是对病人生存率的影响及长期生活质量的影响。新药上市之前,要经过严格的Ⅰ,Ⅱ期临床试验,以观察药物对患者的数周或数月的治疗效果,观察指标往往是某种疾病的一种或几种临床表现（症状、…     

重视老年病临床工作中的循证医学和费-效医学

循证医学(EBM)诞生于20世纪90年代，是被称为“里程碑”的医学进展，其核心思想是任何医疗决策都应建立在新近最佳临床科学研究证据基础上，以保证决策的科学化。循证医学的理念正逐渐渗透到医学的各个领域，以指导卫生管理、高层决策、医学教育、临床实践和科学研究等。但根据循证医学所制定的新的诊断治疗方案不一定是最廉价的，故应用循证医学要求的同时，也要考虑到费用效益问题。费-效医学(costeffective medicine，CEM)探索既提高医疗质量又适当削减费用的途径，使有限的医疗资源发挥更大的社会效益和经济效益。     

怎样实践循证医学

近年本刊登载了几篇介绍循证医学的文章 ,使大家对循证医学有了初步的认识。然而 ,从理论上认识循证医学与在临床上实践循证医学仍有一段距离。循证医学不是个沙龙 ,更不是个组织 ,而是一门科学 ,是临床实践的方法学。循证医学即是遵循证据的医学。它要求医生“在为病人提供医疗照顾做临床决策时 ,诚心诚意地、明确地和审慎地运用现有的最佳证据”。其实 ,行医治病 ,从古时的郎中 ,到今日的医生 ,均自觉不自觉地在循证。历代医家将自己的经验写成医书 ,供后人参考循证 ;而今临床日常工作中的诊断依据、治疗依据也是循证。近 10年来所提倡的…     

风湿科医生看循证医学

最近十年,循证医学的理念已经逐渐被我国风湿科医生认识和掌握.由于随机对照试验(RCT)和荟萃(Meta)分析在外部证据中级别最高,许多学者误将RCT和Meta分析等同于循证医学,盲目推崇RCT和Meta分析的结果.一方面是被有偏倚的RCT和Meta分析所误导,或者不恰当地演绎RCT和Meta分析的结果;另一方面是轻率否定目前RCT和Meta分析尚未涉及的领域和问题,动辄就质疑某些专家建议缺乏循证医学的证据,将暂时没有RCT证实的观点均视为谬误,也是不恰当的.其实循证医学的实施过程就是:"最佳证据+医生智慧+患者意愿=正确决策".本文结合风湿免疫科疾病的特点,重点讨论如何抉择循证医学的外部证据.     

循证医学—指导呼吸系统疾病医学实践的新模式

循证医学在临床医学界的兴起，标志着临床医学将从经验医学进入循证医学时代，呼吸系统疾病的医学实践也是如此，循证医学将成为指导处理呼吸系统疾病的有效工具，本文就循证医学如何实施以及为处理某些呼吸系统疾病所提供的证据作一综述。     

循证医学对抗心律失常及降压药物的治疗启示

循证医学也称求证医学,是医学领域的一个新概念。循证医学要求临床药物治疗以科学证据为指导,对治疗结果科学、客观地观察分析,并注意远期效果。与经验医学有所不同,①依据确切的证据进行临床治疗实践;②对药物的疗效评价注重远期效果和预后情况;③治疗结果包含了对患者生活质量及生存情况的影响。     

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2020

In a time of rapidly shifting evidence-based medicine, it is challenging to stay informed of research that modifies clinical practice. To enhance knowledge of practice-changing literature, a group of 7 internists reviewed titles and abstracts in 7 internal medicine journals with the highest impact factors and relevance to outpatient general internal medicine. Coronavirus disease-19 research was purposely excluded to highlight practice changes beyond the pandemic. New England Journal of Medicine (NEJM), The Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine were reviewed. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on relevance to outpatient internal medicine, impact on practice, and strength of evidence. Clusters of articles pertaining to the same topic were considered together. In total, 7 practice-changing articles were included.     

Evidence-Based Knowledge Management: an approach to effectively promote good health-care decision-making in the Information Era

The sharing of information and the growth of knowledge together represent a foundation for the promotion of quality improvement of health care systems. This paper concerns knowledge, not only from an epistemological point of view, but also from a pragmatic one. In our paper, knowledge is discussed as the hub to promote better decision making and continuous professional development. Effective thinking is particularly needed. The critical point is to think about how health care systems can develop both an effective knowledge management network and how health-care organizations can actually be based on it. In this way, knowledge and knowledge hierarchy are defined according to Russel Achkoff’s vision. Generally, knowledge is crucial in decision-making, and Evidence-Based Medicine has its roots in knowledge. In particular, information management is the basis for a significant production of knowledge to promote good health-care decision-making. Thus, relationships between knowledge management and Evidence-Based Medicine are discussed, and a new paradigm is proposed: the Evidence-Based Knowledge Management. Finally, the role of Evidence-Based Knowledge Management within Clinical Governance is discussed together with some considerations about clinical governance implementation problems in Italy.     

中医药在动脉硬化性疾病防治研究中的比较优势及思考

动脉粥样硬化性疾病属于复杂性慢性疾病。其发病机理尚不很清楚。目前国内临床所用西药均由国外创制。中医药科技工作者发挥祖国医学的独特优势,在中医基础理论指导下,从临床实践到药物研发。经过不断摸索,取得了一批重大成果,为动脉硬化性疾病的防治创制出了一批疗效确切,业界认可,并开始走向世界的创制新药。本文扼要介绍了其中最具代表性的重大成果。     

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2021

It can be challenging to identify new evidence that may shift clinical practice within internal medicine. Synthesis of relevant articles and guideline updates can facilitate staying informed of these changes. The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 8 practice-changing articles were included.     

Evidence and Narrative Based Medicine: A Synthesis for Addiction Medicine?

ABSTRACT

Within primary health care, evidenced-based medicine (EBM) remains the primary methodology for examining the efficacy of medical treatments. Although EBM has dramatically improved treatment outcomes, it fails to reflect the full spectrum of factors involved in the care and healing of patients. As a result, many physicians have adopted narrative based medicine (NBM) within their clinical practice and research. Unlike EBM, NBM focuses on examining the intertwining narratives found between physician-patient relationships and society. In the framework of NBM, the physician aims to utilize the narratives of themselves and their patients to address the relational and psychological dimensions involved in both treatment and healing. Currently, there is a growing movement that seeks to reconnect EBM care models of addiction treatment to the larger and more enduring lived experience of personal and family recovery. Such a synthesis could counter the limitations of both EBM and NBM within the future of medicine.     

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2022

It can be difficult for clinicians to stay updated on practice-changing articles.  Synthesis of relevant articles and guideline updates can facilitate staying informed on important new data impacting clinical practice.  The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded.  The New England Journal of Medicine (NEJM), The Lancet, the Journal of the American Medical Association, The British Medical Journal (BMJ), the Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 5 practice-changing articles were included, along with a highlight of key guideline updates.     

基于中医传承辅助平台分析头痛的用药规律

背景近几年,头痛发病率越来越高,年龄趋于年轻化,治疗上,西药不良反应多、复发性高,患者依从性差,常达不到预期的治疗效果,因此中医治疗头痛引起人们的重视。中医从整体观念出发,以辨证论治为原则,根据个体差异予以不同的方药治疗,而总结中医治疗头痛的用药规律十分重要。目的运用中医传承辅助平台(V2.5)软件,分析应用中药方剂治疗头痛的用药规律。方法收集中国知网(CNKI)中治疗头痛的有效方剂,以"头痛""偏头痛""紧张型头痛""神经性头痛"为关键词并含"中医"进行搜索,检索2014年1月-2019年10月相关的文献,筛选有效方剂214首。基于中医传承辅助平台(V2.5)软件,建立治疗头痛的组方数据库,采用平台中的"数据分析"系统进行数据挖掘。结果治疗头痛的214首有效方剂涉及中药243味。用药频次居于前5位的中药分别是川芎(149次)、甘草(122次)、白芍(94次)、当归(88次)、白芷(78次)。四气:温性中药用药频次最高,占40.86%(1048/2565),其次是寒、平、凉、热;五味:辛味中药用药频次最高,占33.70%(1315/3902),其次是甘、苦、酸、咸、涩;归经:主要以肝、脾、心为主。挖掘出核心组合16个,新方8首。结论治疗头痛常用活血化瘀类中药,多与益气补血止痛类药物同用,为临床诊疗头痛提供方法及思路,也为进一步研发新药提供参考。     

Complexity in Graduate Medical Education: A Collaborative Education Agenda for Internal Medicine and Geriatric Medicine

Internal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.     

Methodology reporting in three acute care journals: replication and reliability

As the sciences of emergency medicine and acute care medicine develop, it becomes imperative for researchers in these fields to accurately and completely report the methodology of their investigations. It is only through complete reporting that other investigators can critically examine, replicate, or expand on the results of an investigation. The purpose of our study was to compare the completeness of methodology reporting in three acute care journals, Annals of Emergency Medicine, Critical Care Medicine, and Journal of Trauma. Thirty-eight criteria characteristics necessary for the replication of a clinical trial were identified and grouped into ten categories. The categories were experimental design, recruitment and exclusion of subjects, selection of study sample, subject allocation, therapeutic regimen, blindness, outcome criteria, analysis of confounders, withdrawal of subjects, and statistical analysis. All prospective, interventional, controlled trials appearing in these journals from January 1980 to June 1983 were identified. A total of 45 trials were found. Each trial was read independently by two reviewers to determine whether each of the 38 criteria was clearly reported, not clearly reported, or not applicable. Disagreements were resolved by a third reader (adjudicator). The results are reported as the mean proportion of items clearly reported +/- standard deviation: Annals of Emergency Medicine (n = 16), 0.39 +/- 0.10; Journal of Trauma (n = 18), 0.33 +/- 0.14; and Critical Care Medicine (n = 11), 0.32 +/- 0.09. A one-way analysis of variance found no statistically significant difference between journals with respect to these proportions (P = .25).(ABSTRACT TRUNCATED AT 250 WORDS)     

European School of Internal Medicine (ESIM) in Brighton: experiences and reflections

The European School of Internal Medicine (ESIM) is a meeting aimed at young physicians training in internal medicine throughout Europe. Since 1998 the school has been held annually, and in this report we reflect on our experiences during the recent school in Brighton in July 2010. The school combined a broad mix of lectures, workshops and case presentations covering a variety of rare diseases, and both faculty and residents participated with noticeable enthusiasm, making this a special experience for all of us. The school also provided an opportunity to compare and discuss topical professional issues in internal medicine in Europe and was a memorable social gathering for physicians who share a strong interest in internal medicine.