病因学研究的循证医学评价

病因学研究是寻找疾病的病因或治疗措施的副作用、各种病因因素的相互关系以及它们对疾病发生发展的影响。对病因学研究应该按照循证医学有关病因学文献评价原则，进行病因学研究的真实性、临床重要性和实用性评价。     

The informationist: a prospective uncontrolled study.

OBJECTIVE: To determine whether doctors in an Australian tertiary hospital would use an informationist service, and to identify how the service would influence care. DESIGN: A prospective uncontrolled pilot study July 2002-January 2003. SETTING: A teaching hospital in South Australia. STUDY PARTICIPANTS: Fourteen doctors working in the selected units. INTERVENTION: An informationist attended specified medical in-patient ward rounds and clinical meetings in the Respiratory Medicine, Sleep Disorders, and Rheumatology units. Main outcomes measures. Clinician self-assessed impact of information on a range of outcomes relating to clinical decision-making, clinician education, and avoidance of adverse events. RESULTS: In 23 weeks, 52 questions were generated by nine of 14 eligible doctors. Forty-eight of 52 (92%) feedback forms were completed, indicating an average of 5.7 impacted outcomes per response. Twenty-five of 48 (52%) provided new information to doctors, and 24/48 (50%) provided at least some information that could be used immediately. Most common contributions of the service to patient care were revision of treatment plan (21/48, 44%) and confirmation of proposed therapy (18/48, 38%). Thirteen of 48 (27%) contributed to avoiding adverse events, and 10/48 (21%) contributed to avoiding additional tests and procedures. Eleven of 11 (100%) doctors who used the service assessed that it contributed or probably contributed to their professional development, with 8/10 (80%) indicating a similar impact on improving clinical outcomes. CONCLUSION: Medical staff will use an informationist service, which contributes substantially to a multiplicity of outcomes relating to medical decision-making, clinician education, and clinical outcomes.     

Evidence-based medicine and public health

Much of the everyday work of public health professionals is concerned with the implementation of evidence-based medicine (EBM). Is this likely to improve the quality of the health service that patients' receive? In this paper, I argue that EBM is unlikely, by itself, to improve the dimensions of quality as defined by Maxwell (1994). This is because EBM relies on the individual doctor doing the right thing all of the time. Open systems theory is a way of looking at the influences of the environment on individual clinical behaviour. Using this perspective, it is easy to see why EBM will fail to improve patient care dramatically. The environment in which we work is a much bigger influence on us than we care to admit. I use some published examples to look at the way that the environment affects clinical behaviour to the detriment of the overall service quality. As public health professionals, we should be more concerned with the outcome of the service than with the specifics of a particular consultation. In this context, EBM is likely not to be a very useful tool for public health professionals.     

试验组对照组的氨氯地平降压效果组别偏倚的实证研究

目的：了解临床试验中同一药物作为试验药和对照药时，被观察的疗效结果是否存在差别。方法：按照一定的标准，通过《中国医院数字图书馆》收集氨氯地平的随机对照临床试验，比较试验组与对照组氨氯地平的降压结果。结果：收集到19篇文献。氨氯地平试验组群的加权平均总有效率为88．58％，对照组群为79．34％；两组群的Ridit值分别为0．5411和0．4370；试验组群的降压结果比对照组群高11．6％或12．4％；两组群总有效率和Ridit值存在显著性差异（P〈0．01）；两组群中一些研究的降压结果存在差异（P〈0．01），但各组群内的结果一致。结论：在非双盲随机对照试验中，试验组药物的疗效可能被夸大或对照组被贬低。应重视这种偏倚在新药临床试验和Meta分析中的影响。     

Clinical audit in the National Health Service: fact or fiction?

It is increasingly recognized that the repeated rhetorical emphasis from 1989 to date on achieving measurable benefits to patients from audit, in the face of inattention to the development of methodologies with which to realize such benefits in operational practice, has represented a serious deficiency in strategic planning and direction and a consequent failure to establish functional clinical audit within the NHS. A grand revision of strategy is therefore necessary, and this should begin with the development of a research-based method of audit, the training of clinicians and audit support staff in its use and a subsequent trial of its effectiveness prior to its implementation within the NHS. Only then will measurable improvements become possible, value for money be assured and clinicians' attitudes to audit change.     

The Death of Treatment as Usual: An Excellent First Step on a Long Road

The failure of system reforms to affect child and family outcomes and the lack of positive findings concerning treatment as usual has led to pressure to reform treatment in the community through the adoption of evidence-based treatments. While this is generally a positive direction for the future, reformers should also consider the quality of evidence supporting these treatments and the dependence on traditional diagnostic approaches as limitations to this approach. Moreover, reformers should recognize the importance of learning from clinicians and consumers, the inclusion of a common factors approach and the critical role of measurement in the reform process.     

用循证的方法看医疗质量概念的延伸

医疗质量是医院建设的永恒主题。随着社会的发展，医疗质量的内涵也有了新的延伸。本文从循证的角度，探讨了医疗质量的新概念。     

肠外营养临床有效性的大样本临床研究与系统评价

肠外营养（PN）的发展推动了临床营养的进步，但过度应用可能造成的不良反应已引起关注，1991年美国VA研究发现，PN对无严重营养不良的患不仅无益，反而可能有害。2001年美国胃肠病学会运用循证医学方法对PN临床有效性进行了评价。合并所有纳入研究的总Meta分析发现，与空白对照相比，PN对死亡率和总并发症发生率无影响。但感染率明显较高。进一步的亚组分析发现PN的疗效与患类型有关。对择期术后患PN能降低并发症，最近我们基于高质量中研究的Meta-分析也发现，较之PN，使用肠内营养（EN）患的肝功能受影响更少，并有助于节省费用，虽然上述证据提示EN有较多优势，但患方面的需求也在很大程度上决定营养支持方式的选择。临床医生需要结合患和客观证据两方面考虑对营养支持途径的选择。     

循证医学对钙拮抗剂在心血管病治疗地位的评价

近10年来随着多中心、随机、双盲、安慰剂对照、长期和大规模临床试验的开展，钙拮抗剂在心血管病治疗中的地位日渐明朗。现将循证医学对钙拮抗剂在心血管病治疗现状的评价及未来研究的方向进行综述。