戴启明医师.ppt

EBM worksheet Clinical scenario Background knowledge Question by PICO Search strategy Search outcome Citations Evidence appraisal Conclusion Plain-language explanation 特徵 再出血率 Forrest I Active bleeding Ia Active pulsation 90% Ib Active oozing 30% Forrest II Bleeding stigmata IIa Visible vessel 50% IIb Clot 20% IIc Black base 5% Forrest III No bleeding signs Clear ulcer base 5% pH Matters Intragastric pH3: Correlated with DU healing1 Intragastric pH4: Correlated with healing of gastric ulcer2 erosive esophagits3 Intragastric pH6: Correlated with clot formation 4,5 prevention of ulcer rebleeding 1Johnes DB et al. Gut 1987; 28:1120-7 2Bell NJV et al. Digestion 1992; 51(suppl 1): 59-67 3Howden CW et al. Aliment Pharmacol Ther 1990; 4:25-33 4Green FJ et al. Gastroenterology 1978; 74:38-43 5Patchett SE et al. Gut 1989; 30:1704-7 Bolus Followed by Bolus 4. Search strategy-2 Search PubMed for ulcer bleeding and proton-pump inhibitor -- 390 papers found Limits: English,human,meta-analysis,RCT -- 52 papers found Limits: English,human,meta-analysis, -- 19 papers found 6. Citations Meta-analysis: proton-pump inhibition in high-risk patients with acute peptic ulcer bleeding. Aliment Pharmacol Ther. 2005 Mar 15;21(6):677-86  METHODS: MEDLINE was used to identify randomized trials (01/1990-04/2003) that assessed the efficacy of pharmacological treatments for patients with bleeding peptic ulcers exhibiting high-risk stigmata (Forrest Ia-IIb). Three groups of treatment were assessed: proton-pump inhibitors given as ? high-dose bolus followed by intravenous constant infusion ? ? ? ? ? (40-80 mg and at least 6 mg/h), ? high-dose oral proton-pump inhibitors ? ? ? ? ? (at least twice the standard dosage), ? non-high-dose proton-pump inhibitors ? ? ? ? ? (other proton-pump inhibitors dosing schedules) ? Mixed-effect models were used to determine rate differences between t