循证医学在骨伤临床中的意义

循证医学(evidence—based medicine，EBM)即遵循科学依据的医学。其核心思想是：任何医疗决策的确定，即医生处理患者、制定治疗措施、政府制定医疗卫生政策等，都应根据现有客观的、最可靠的科学依据进行。在疾病的治疗过程中，应将个人的临床专业知识与现有最好的临床科学研究证据结合起     

基于循证指南和精准医学时代背景下肝癌诊疗的思考与总结

正信息时代,瞬息万变,新的医学理念和技术层出不穷,不断更新着人们对于疾病的认知模式。近些年来,诸多国家和地区遵循循证医学,筛选出最可靠并具有一定的临床运用价值的研究成果,更新发表了各种专家共识或临床指南,指导世界各地医师的诊疗[1]。肝癌的诊治作为全球性的难     

精准医学在胃癌中的研究进展

得益于各种分子生物学技术以及基因测序等的进步,胃癌在发病机制研究、分子分型以及靶向治疗等方面有不小的突破.借助于最新的液体活检技术,在评判胃癌病人预后以及对药物或者治疗的反应性方面有了突飞猛进的发展.而光学和物理学的进步推动了内窥镜在胃癌早期诊断以及早期治疗中的发展,同时推动了腹腔镜在进展期胃癌中的广泛开展,高清3D腹...     

循证医学与修复重建外科

循证医学（evidence-based medicine,EBM)兴起于20世纪90年代初,是加拿大麦克玛斯特大学的David Sackett教授及同事在长期临床流行病学实践基础上提出的一个崭新的医学概念和医学模式^[1]。在短短的10年间,循证医学的理论体系、技术体系已逐渐形成,其实践应用更是随着国际Cochrane协作网的建设和微机网络技术的突飞猛进而不断完善,并在临床医学领域迅速发展,成为当前国际临床医学的热点之一。     

循证医学在肾脏病实践中的作用

自ＤａｖｉｄＳａｃｋｅｔｔ上个世纪九十年代明确提出循证医学的概念以来 ,循证医学已成为近年来国际临床医学界倡导的学科发展方向之一。循证医学(Ｅｖｉｄｅｎｃｅ-ＢａｓｅｄＭｅｄｉｃｉｎｅ ,ＥＢＭ ) ,即遵循证据的科学 ,Ｓａｃｋｅｔｔ教授将ＥＢＭ定义为“慎重、准确和明智地应用所获得的最好研究依据来确定患者的治疗措施”。其核心思想是 :医疗决策应尽量以客观的研究结果为依据。医生开具处方、制订治疗方案或医疗指南 ,政府机构作出医疗卫生决策等 ,都应根据现有的、最好的研究结果进行〔1〕。1　为什么肾脏病学要开展循证医学…     

循证医学与外科临床经验总结

鉴于目前外科临床经验总结不少还存在一些不科学部分，有必要强调循证医学概念在外科经验总结中贯彻的重要意义，兹就循证医学的概念及其中临床试验、治疗结局研究和临床实践指导准则等要求加以复习。     

在普通外科诊疗实践中正确掌握和合理运用循证医学原则

普通外科逐步进入循证医学时代.但目前外科领域的循证医学研究数量少,质量不高.外科医生应重视循证医学研究,更现实的是利用好现有的循证医学资料.在此过程中,应对循证医学资料仔细分析,并在临床实践中合理运用,即在适当的时候,适合的病人中应用循证医学原则.     

临床医学中的循证医学

临床医师日常门诊或查房工作中总是会在具体病人的诊治上产生一些问题。一般而言都是根据医师的经验,上级医师的教导,对其病理、病理生理、临床共识、专业书籍、杂志和教材的记载来作出选择。美1994年有统计表明,仅30%全科医师,75%的专科医师在治疗消化性溃疡中应用四联用药治疗幽门螺旋杆菌。虽然早已确定消化性溃疡治疗中此种幽门螺旋菌治疗的重要性,对疗效的提高和防止溃疡复发都已肯定。此统计结论中归咎于象1992版《西氏内科学》教材中对此阐述仍停留在80年代理解水平。此种现象国内更为突出,而且持续至今仍未得到纠正。它说明医学知识…     

比较医学与循证医学的有机结合在新世纪外科发展中的意义

比较医学(comparative medicine)和循证医学(evidence-basedmedicine)分别是20世纪80年代和90年代新兴的两门边缘学科。比较医学是以实验动物为主要研究对象的实验医学，循证医学是以患者为主要研究对象的临床医学。两者虽各有特点，但却是密不可分的。开展比较医学的最终目的是将动物实验的结果推论及人体，为了实现这一理想，     

美国结直肠外科医师协会结肠癌治疗规范（2012版）精要及解读

美国结直肠外科医师协会（ASCRS）2012年7月公布的最新的结肠癌治疗指南是由美国知名专家组成的委员会根据2004—2010年的文献检索和循证医学证据进行汇总后制订的,更新了包括结肠癌的术前评估、分期、外科治疗以及相关的急诊手术、局部复发的处理和辅助治疗等一些诊疗中的细节。现归纳其要点并进行解读。     

Best practice wound care

This article describes the barriers, changes and achievements related to implementing one element of a wound care programme being best practice care. With the absence of a coordinated approach to wound care, clinical practice within our Area Health Service (AHS) was diverse, inconsistent and sometimes outdated. This was costly and harmful, leading to overuse of unhelpful care, underuse of effective care and errors in execution. The major aim was to improve the outcomes and quality of life for patients with wound care problems within our community. A collaborative across ten sites/services developed, implemented and evaluated policies and guidelines based on evidence-based bundles of care. Key barriers were local resistance and lack of experience in implementing structural and cultural changes. This was addressed by appointing a wound care programme manager, commissioning of a strategic oversight committee and local wound care committees. The techniques of spread and adoption were used, with early adopters making changes observable and allowing local adaption of guidelines, where appropriate. Deployment and improvement results varied across the sites, ranging from activity but no changes in practice to modest improvement in practice. Evaluating implementation of the leg ulcer guideline as an exemplar, it was demonstrated that there was a statistically significant improvement in overall compliance from 26% to 84%. However, only 7·7% of patients received all interventions to which they were entitled. Compliance with the eight individual interventions of the bundle ranged from 26% to 84%. Generic performance was evaluated against the wound assessment, treatment and evaluation plan with an average compliance of 70%. Early results identified that 20% of wounds were healed within the target of 10 days. As more standardised process are implemented, clinical outcomes should continue to improve and costs decrease.     

精准医学在结直肠外科中的内涵与临床实践

2015年,美国医生Francis S.Collins在著名的新英格兰医学杂志上撰文介绍了精准医学的概念。精准医学是近年来出现的新的医学概念。它是以分子基因为基础实现对疾病的诊断和治疗。我们已经进入了一个精准医学的时代。我们也经历了经验医学,循证医学,现在又进入了精准医学的时代。今天,在结直肠癌领域,我们已经看到:精准医学已经在结直肠癌的姑息治疗中发挥着重要作用,如:常用的爱必妥,安维汀和帕尼单抗等。因此,结直肠外科医生应该认真地学习精准医学的概念,了解精准医学在结直肠领域的独特作用。同时,我们也要应用精准医学的概念去认识和解决结直肠癌领域亟待解决的科学问题。而且,我们也要看到精准医学的局限性,客观公正地评价精准医学。     

多模式临床支持系统的研究进展

目的探讨多模式临床支持系统的研究进展。方法通过了解国际多模式临床支持系统发展和运作情况,并与传统的临床支持系统进行对比,探讨多模式临床支持系统的国际研究进展情况。结果在多模式临床支持系统概念、目的及特点认识的基础上,了解了多模式临床支持系统的国际进展情况。结论临床支持系统模式的发展和演变,为多学科协作诊治模式提供了新的临床辅助,加强了循证医学的临床实践和相应的提升体系,但临床支持系统项目在目前我国医院的应用还需要进一步探讨和研究。     

精准医学在胃肠肿瘤外科中的内涵与临床实践

随着基因组学、影像诊断和外科技术的发展,胃肠肿瘤的外科治疗开始逐步迈向"精准医学时代"。肿瘤的精准外科治疗是在标准根治术的基础上,利用现代影像学和分子病理诊断技术对肿瘤类型及分期进行精确判断,术前制定详细的治疗计划、术中运用现代外科技术精细操作最大限度减少手术创伤及保留脏器功能,快速促进患者康复。本专题中我们将探讨精准医学在胃肠肿瘤外科中的内涵与实践,旨在进一步推广精准治疗理念,推进我国胃肠肿瘤防治事业的进步。     

A pilot investigation of a pediatric surgery journal club

Background

The CanMEDS competency “scholar” encompasses the creation, dissemination, application, and translation of medical knowledge. We hypothesize that a structured journal club (JC) for pediatric surgical trainees would meet these objectives in an enjoyable and long-lasting manner.

Methods

A JC involving two pediatric surgery training programs was created with each session focusing on a specific study design. Pre-tests/post-tests were administered before/after each session with durability of learning assessed during the following session. Metrics analyzed included participant satisfaction and an appraisal of evidence-based medicine (EBM) principals. Test results were analyzed using the paired T-test with p < 0.05 considered significant.

Results

On average, 14 participants attended each session, with all trainees present (4). While participants believed they understood EBM principles, 40% were unfamiliar with question formulation, 48% were unfamiliar with critical appraisal tools, and 60% had not appraised an article within the previous year. Pre-test to post-test comparison yielded an improvement in mean score (20 = perfect score): 10.8 to 16.9, p < 0.01. Measures of participant satisfaction were uniformly positive.

Conclusion

A structured Pediatric Surgery Journal Club addresses scholarly training objectives in a highly satisfactory manner and yields durable learning. A web-based curriculum based on this model could serve as an important educational tool for trainees and attending staff alike.     

Evidence-based medicine

Evidence based medicine is the practice of solving the clinical problems in one''s practice by judicious and systematic use of the medical literature. This includes framing questions rightly and searching the right kind of literature. Thereafter, the available evidence needs to be evaluated for the validity, strength and effect size. Finally, the results are examined for applicability to the current problem which requires a detailed knowledge of the clinical setting, patient profile and the issues related to cost and harm. The present communication deals with these issues in a step-wise manner in order to stimulate readers to practise this important art.     

Clinical epidemiology of testicular germ cell tumors

Clinical epidemiology is sometimes called the basic science of clinical medicine. In terms of the pathogenesis of testicular germ cell tumors (GCTs), clinical epidemiology analyzes suspected risk factors. The present review highlights the risk factors established so far and briefly summarizes those factors currently under investigation. In analogy to the methods of evidence based medicine, this review attributes levels of evidence to each of the putative risk factors. Level I represents highest quality of evidence while level V denotes the lowest level. So far, undescended testis (UDT), contralateral testicular GCT and familial testis cancer are established risk factors attaining high levels of evidence (levels I–III a). In a meta-analysis of 21 studies exploring the association of UDT with GCT risk, an over-all relative risk (RR) of 4.8 (95% confidence interval 4.0–5.7) was found. Contralateral testicular GCT involves a roughly 25-fold increased RR of GCT, while familial testis cancer constitutes a RR of 3–10. Infertility, testicular atrophy, and twin-ship represent risk factors with lesser levels of evidence (level III a). There is also some evidence for HIV infection being a predisposing factor for GCT (level IV a). Scrotal trauma is probably not associated with GCT risk. The estrogen excess theory implies high estrogen levels during the first trimester of pregnancy. As a consequence, primordial germ cells lose track of the normal developmental line and transform into premalignant cells that later become testicular intraepithelial neoplasia (TIN), the precursor of full-blown testicular GCT. Surrogate parameters for high gestational estrogen levels are investigated in case control studies. Such factors are maternal age >30 years, first-born, low birth weight, maternal breast cancer, high sex-ratio of siblings. So far, the sum of evidence is promising but still conflicting (especially for level III b). Another novel theory is the childhood nutrition hypothesis. This concept postulates a modulating or catalyzing effect by high dietary intake during childhood on the pathogenesis of testicular GCT. A surrogate parameter of early childhood nutrition is adult height. So far, 12 controlled studies have looked to the possible association of attained height and GCT risk of which six demonstrated a significant association. Thus, the sum of evidence corresponds to level III b. This concept is appealing because it would explain several hitherto unexplained epidemiological features of GCT.     

Evidence-based practice standards for the use of topical pressurised oxygen therapy

Whenever a new therapy enters the wound care arena it is mandatory to deliver the best evidence to clinicians, healthcare administrators and policy makers to support integration of the technology into clinical practice. While this can often be problematic when novel therapies lack a large body of supporting evidence, methods that incorporate the use of expert opinion do exist to evaluate existing evidence and create consensus statements that can help guide decisions. Topical pressurised oxygen therapy is a method of delivering pressurised and humidified oxygen directly to the wound bed to support the healing of chronic and hypoxic wounds. This article will present the process by which the evidence was identified and evaluated as well as present standards based on the evidence related to topical pressurised oxygen therapy. We will show, through the use of the evidence, how this therapy can be a non invasive safe approach for wound management for selected patients in all clinical care settings.     

The future of publishing

This is the first Journal of Pediatric Surgery lecture at the Pacific Association of Pediatric Surgeons (PAPS) meeting.