实证医学竞赛-CAT摘要课件

實證醫學競賽－CAT摘要組別：第(A)組實證醫學競賽－CAT摘要1訂定PICOP:acutepancreatitiswithabdominalpainI:PerscriptionofdrugsC:Morphine,demerol,otheranalgesicsO:Efficacyofpaincontrol訂定PICOP:acutepancreatitisw2資料庫來源1.Pubmed2.MedlineOvid3.Uptodate4.Googlescholar資料庫來源1.Pubmed3搜尋之關鍵字1.Pancreatitisandpainmanagement2.Pancreatitisandmorphine3.Pancreatitisand“demerolormeperidineorpethidine”搜尋之關鍵字1.Pancreatitisandpain4搜尋之歷程請列出你們搜尋的歷程。搜尋之歷程請列出你們搜尋的歷程。5文獻研讀1.Efficacyandtoleranceofmetamizoleversusmorphineforacutepancreatitispain.

PeiróAM,MartínezJ,MartínezE,deMadariaE,LlorensP,HorgaJF,Pérez-MateoM.Pancreatology.2008;8(1):25-9.Epub2008Jan31.PMID:18235213[PubMed-indexedforMEDLINE]2.AmJGastroenterol.2001Apr;96(4):1266-72.NarcoticanalgesiceffectsonthesphincterofOddi:areviewofthedataandtherapeuticimplicationsintreatingpancreatitis.ThompsonDR.DepartmentofInternalMedicine,BaylorUniversityMedicalCenter,Dallas,Texas75246,USA.文獻研讀1.Efficacyandtolerance6Efficacyandtoleranceofmetamizoleversusmorphineforacutepancreatitispain.AbstractBackground/Aims:Morphinehasbeencontraindicatedforpaintreatmentinacutepancreatitisbecauseofitspresumedopioid-inducedsphincterofOddidysfunction.However,scientificevidencesupportingadeleteriousinfluenceontheclinicalcourseisabsent.Thispilotstudywasundertakentoevaluatetheefficacyandadverseeventsofmetamizoleversusmorphineinacutepancreatitis.Methods:16patientswithacutepancreatitiswererandomizedtoreceive10mg/4hs.c.(n=8)morphineor2g/8hi.v.(n=8)metamizole.Painscoreswererecordedevery4hduring48hafteradmissionbyaVisualAnalogueScale.Pethidinewasadditionallyadministeredasarescuetherapy.Results:75%ofpatientsachievedpainreliefinthemetamizolegroupversus37.5%inthemorphinegroupwithin24hofhospitalization(6/8vs.3/8;p:n.s.).Themeantimetoachievepainreliefwasshorterinthemetamizolegroup(1086.6vs.17818.3h;p:n.s.).Attheendofthestudy,75%ofpatientsachievedpainreliefinthemetamizolegroupversus50%inthemorphinegroup.Threepatientsineachgroupneededpethidine:2outof3achievedpaincontrolinthemetamizolegroupvs.0outof3inthemorphinegroup.Conclusions:Intravenousmetamizoleshowsanon-significantassociationwithaquickerpainreliefthanmorphines.c.inacutepancreatitis.Alargerrandomizedcontrolledtrialshouldbedesirabletoconfirmthisresult.Efficacyandtoleranceofmeta7实证医学竞赛-CAT摘要课件8NarcoticanalgesiceffectsonthesphincterofOddi:areviewofthedataandtherapeuticimplicationsintreatingpancreatitis.

AmJGastroenterol.2001Apr;96(4):1266-72.NarcoticanalgesiceffectsonthesphincterofOddi:areviewofthedataandtherapeuticimplicationsintreatingpancreatitis.ThompsonDR.DepartmentofInternalMedicine,BaylorUniversityMedicalCenter,Dallas,Texas75246,USA.AbstractOBJECTIVE:Traditionalteachingdictatesthatmorphineinduces"spasm"inthesphincterofOddi(SO)andshouldnotbeusedinacutepancreatitisandthatmeperidineistheanalgesicofchoicebecauseitdoesnotelevateSOpressures.Aliteraturesearchandreviewwasperformedtoevaluatethisteachingexaminingtheeffectofnarcoticanalgesic'seffectsonSO.METHODS:AMedlinesearchwasperformedusingkeywordsandphrases.Themanufacturersofmeperidinewerecontactedandtheirreportsandstudieswereobtainedandreviewed.RESULTS:Initialstudiesmeasuredbiliarypressureafternarcoticadministrationinanimals,andpostoperativeandintraoperativecholecystectomypatients.Allnarcoticsincreasedbiliarypressure,butmorphinewasassociatedwiththelargestelevation.LaterstudiesusingendoscopicretrogradecholangiopancreatographywithdirectSOmanometrydemonstratedthattheSOisexquisitelysensitivetoallnarcoticsincludingmeperidineandthatasmallincreaseinbiliarysphincterpressureisseenwithhigherdosesofmorphine.AllnarcoticsincreaseSOphasicwavefrequencyandinterferewithSOperistalsis.CONCLUSIONS:Narcotic-inducedincreasesinphasicwavefrequencyinterferewithSOfillingandareresponsiblefortheincreaseinbileductpressureseenontheinitialstudies.NostudiesdirectlycomparetheeffectsofmeperidineormorphineonSOmanometryandnocomparativestudiesexistinpatientswithacutepancreatitis.Nooutcome-basedstudiescomparingthesedrugshavebeenperformedinpatientswithacutepancreatitis.Morphinemaybeofmorebenefitthanmeperidinebyofferinglongerpainreliefwithlessriskofseizures.Nostudiesorevidenceexisttoindicatemorphineiscontraindicatedforuseinacutepancreatitis.Narcoticanalgesiceffectson9結論1.Meperidine

hastraditionallybeenfavoredovermorphine

foranalgesiainpancreatitis,probablybecausehumanstudiesshowedthatmorphinecausedanincreaseinsphincterofOddipressure2.Despitethesedatathereisnoclinicalevidencetosuggestthatmorphinecanaggravateorcausepancreatitis.3.Repeateddosesofmeperidinecanleadtoaccumulationofthemetabolitenormeperidinethatcausesneuromuscularirritationand,rarely,seizures.Morphinemaybeofmorebenefitthanmeperidinebyofferinglongerpainreliefwithlessriskofseizures4.Intravenousmetamizoleshowsanon-significantassociationwithaquickerpainreliefthanmorphines.c.inacutepancreatitis.Alargerrandomizedcontrolledtrialshouldbedesirabletoconfirmthisresult.結論1.Meperidine

hastraditiona10如何應用於臨床？1.沒有強力証據顯示Demerol比morphine好2.使用Demerol需小心seizure的風險3.Metamizole也許是臨床上更好的選擇,仍需更多RCT如何應用於臨床？1.沒有強力証據顯示Demerol比morp11困境或陷阱目前仍無強力RCT證明何者為佳需要更多Trial困境或陷阱目前仍無強力RCT證明何者為佳12參考資料：證據的強度參考資料：證據的強度13參考資料：證據等級和臨床建議GradeofRecommendationLevelofEvidenceTherapy[A]1aSystemicreviewofRCTs1bSingleRCT1c‘All-or-none’[B]2aSystemicreviewofcohortstudies2bCohortstudyorpoorRCT2c‘Outcomes’research3aSystemicreviewofcase-controlstudies3bCase-controlstudy[C]4Caseseries[D]5Expertopinion,physiology,benchresearch參考資料：證據等級和臨床建議GradeofRecomme14參考資料參考資料15實證醫學競賽－CAT摘要組別：第(A)組實證醫學競賽－CAT摘要16訂定PICOP:acutepancreatitiswithabdominalpainI:gabexatemesilateC:placeboO:complication,mortality,morbidity,abdominalpain訂定PICOP:acutepancreatitisw17資料庫來源PubmedCochraneUptodate資料庫來源Pubmed18搜尋之關鍵字請列出你們用了哪些關鍵字。搜尋之關鍵字請列出你們用了哪些關鍵字。19搜尋之歷程請列出你們搜尋的歷程。搜尋之歷程請列出你們搜尋的歷程。20文獻研讀請列出你們認為證據最強的相關文獻一至三篇針對每篇文獻，請摘錄其：題目及出處(e.g.Dosingandsafetyofcyclosporineinpatientswithseverebraininjury.JNeurosurg.2008;109(4):699-707)研究設計(studydesign)結果(若有計算NNT、RR、OR等，請一併列出)證據等級(levelofevidence)文獻研讀請列出你們認為證據最強的相關文獻一至三篇21第一篇Prospectiveandrandomizedstudyofgabexatemesilateforthetreatmentofsevereacutepancreatitiswithorgandysfunction.(Hepatogastroenterology.2000Jul-Aug;47(34):1147-50)METHOD:52patientswithacutepancreatitisandorgandysfunctionwereenrolled.Thetreatmentgroupincluded26patientsreceivingintravenousgabexatemesilateinfusionatadoseof100mg/hrfor7days.APACHE-IIscore,clinicalandbiochemicalparametersweremonitoredintensively.CONCLUSION:Coagulopathyileus,andabdominalpainwassignificantlyimprovedwithgabexatemesilate.Gabexatemesilatereducedthenecessityforsurgicalinterventionandperitoneallavage.The7-day-mortalityand90-day-mortalityrateswerealsosignificantlyreducedwithgabexatemesilatetherapy.EVIDENCELEVEL:RCT,levelIb(gradeA)第一篇Prospectiveandrandomized22第二篇Clinicaltrialwithaproteaseinhibitorgabexatemesilateinacutepancreatitis.(IntJPancreatol.1991Summer;9:75-9)Retrospectiveanalysisof23patientswithsevereAPand88withmildtomoderateAPwhoweretreatedinourinstituteandfouraffiliatedmedicalcentersduringthe10-yperiodfrom1980to1990.Intravenousinfusionofaproteaseinhibitor,GabexateMesilate(FOY),wasstartedwithin24hfromonsetofAP(earlyadministration)in17patientswithsevereAPand51withmildtomoderateAP.TheremainingpatientswereputonFOYlaterthan24hfromonsetofAP(lateadministration).Comparisonofthemortalityandmorbiditybetweenthetwogroups,earlyvslateadministrationofFOY,ledtothefollowingconclusions:(1)EarlyadministrationofFOYsignificantlyimprovedmortality(29.4vs83.3%)insevereAP,althoughtheimprovementinmortalitywasnotdirectlyproportionaltotheshorteningofthetimelagbetweentheonsetofAPandthestartofFOY,and(2)earlieradministrationofFOYbroughtaboutsignificantlyearlierrecoveryofabdominalpain,hyperamylasemia,andleucocytosisinmildtomoderateAP.EVIDENCELEVEL:LEVELIIb(gradeB)第二篇Clinicaltrialwithaprote23結論與臨床應用UseofFOYforacutepancreatitisreducesmortalityandmorbidity,especiallyifusedearly.結論與臨床應用UseofFOYforacutepa24困境或陷阱Thesestudiesfocusonseverepancreatitisandlessonmildormoderate.困境或陷阱Thesestudiesfocusonse25謝謝聆聽謝謝聆聽26實證醫學競賽－CAT摘要組別：第(A)組實證醫學競賽－CAT摘要27訂定PICOP:acutepancreatitiswithabdominalpainI:PerscriptionofdrugsC:Morphine,demerol,otheranalgesicsO:Efficacyofpaincontrol訂定PICOP:acutepancreatitisw28資料庫來源1.Pubmed2.MedlineOvid3.Uptodate4.Googlescholar資料庫來源1.Pubmed29搜尋之關鍵字1.Pancreatitisandpainmanagement2.Pancreatitisandmorphine3.Pancreatitisand“demerolormeperidineorpethidine”搜尋之關鍵字1.Pancreatitisandpain30搜尋之歷程請列出你們搜尋的歷程。搜尋之歷程請列出你們搜尋的歷程。31文獻研讀1.Efficacyandtoleranceofmetamizoleversusmorphineforacutepancreatitispain.

PeiróAM,MartínezJ,MartínezE,deMadariaE,LlorensP,HorgaJF,Pérez-MateoM.Pancreatology.2008;8(1):25-9.Epub2008Jan31.PMID:18235213[PubMed-indexedforMEDLINE]2.AmJGastroenterol.2001Apr;96(4):1266-72.NarcoticanalgesiceffectsonthesphincterofOddi:areviewofthedataandtherapeuticimplicationsintreatingpancreatitis.ThompsonDR.DepartmentofInternalMedicine,BaylorUniversityMedicalCenter,Dallas,Texas75246,USA.文獻研讀1.Efficacyandtolerance32Efficacyandtoleranceofmetamizoleversusmorphineforacutepancreatitispain.AbstractBackground/Aims:Morphinehasbeencontraindicatedforpaintreatmentinacutepancreatitisbecauseofitspresumedopioid-inducedsphincterofOddidysfunction.However,scientificevidencesupportingadeleteriousinfluenceontheclinicalcourseisabsent.Thispilotstudywasundertakentoevaluatetheefficacyandadverseeventsofmetamizoleversusmorphineinacutepancreatitis.Methods:16patientswithacutepancreatitiswererandomizedtoreceive10mg/4hs.c.(n=8)morphineor2g/8hi.v.(n=8)metamizole.Painscoreswererecordedevery4hduring48hafteradmissionbyaVisualAnalogueScale.Pethidinewasadditionallyadministeredasarescuetherapy.Results:75%ofpatientsachievedpainreliefinthemetamizolegroupversus37.5%inthemorphinegroupwithin24hofhospitalization(6/8vs.3/8;p:n.s.).Themeantimetoachievepainreliefwasshorterinthemetamizolegroup(1086.6vs.17818.3h;p:n.s.).Attheendofthestudy,75%ofpatientsachievedpainreliefinthemetamizolegroupversus50%inthemorphinegroup.Threepatientsineachgroupneededpethidine:2outof3achievedpaincontrolinthemetamizolegroupvs.0outof3inthemorphinegroup.Conclusions:Intravenousmetamizoleshowsanon-significantassociationwithaquickerpainreliefthanmorphines.c.inacutepancreatitis.Alargerrandomizedcontrolledtrialshouldbedesirabletoconfirmthisresult.Efficacyandtoleranceofmeta33实证医学竞赛-CAT摘要课件34NarcoticanalgesiceffectsonthesphincterofOddi:areviewofthedataandtherapeuticimplicationsintreatingpancreatitis.

AmJGastroenterol.2001Apr;96(4):1266-72.NarcoticanalgesiceffectsonthesphincterofOddi:areviewofthedataandtherapeuticimplicationsintreatingpancreatitis.ThompsonDR.DepartmentofInternalMedicine,BaylorUniversityMedicalCenter,Dallas,Texas75246,USA.AbstractOBJECTIVE:Traditionalteachingdictatesthatmorphineinduces"spasm"inthesphincterofOddi(SO)andshouldnotbeusedinacutepancreatitisandthatmeperidineistheanalgesicofchoicebecauseitdoesnotelevateSOpressures.Aliteraturesearchandreviewwasperformedtoevaluatethisteachingexaminingtheeffectofnarcoticanalgesic'seffectsonSO.METHODS:AMedlinesearchwasperformedusingkeywordsandphrases.Themanufacturersofmeperidinewerecontactedandtheirreportsandstudieswereobtainedandreviewed.RESULTS:Initialstudiesmeasuredbiliarypressureafternarcoticadministrationinanimals,andpostoperativeandintraoperativecholecystectomypatients.Allnarcoticsincreasedbiliarypressure,butmorphinewasassociatedwiththelargestelevation.LaterstudiesusingendoscopicretrogradecholangiopancreatographywithdirectSOmanometrydemonstratedthattheSOisexquisitelysensitivetoallnarcoticsincludingmeperidineandthatasmallincreaseinbiliarysphincterpressureisseenwithhigherdosesofmorphine.AllnarcoticsincreaseSOphasicwavefrequencyandinterferewithSOperistalsis.CONCLUSIONS:Narcotic-inducedincreasesinphasicwavefrequencyinterferewithSOfillingandareresponsiblefortheincreaseinbileductpressureseenontheinitialstudies.NostudiesdirectlycomparetheeffectsofmeperidineormorphineonSOmanometryandnocomparativestudiesexistinpatientswithacutepancreatitis.Nooutcome-basedstudiescomparingthesedrugshavebeenperformedinpatientswithacutepancreatitis.Morphinemaybeofmorebenefitthanmeperidinebyofferinglongerpainreliefwithlessriskofseizures.Nostudiesorevidenceexisttoindicatemorphineiscontraindicatedforuseinacutepancreatitis.Narcoticanalgesiceffectson35結論1.Meperidine

hastraditionallybeenfavoredovermorphine

foranalgesiainpancreatitis,probablybecausehumanstudiesshowedthatmorphinecausedanincreaseinsphincterofOddipressure2.Despitethesedatathereisnoclinicalevidencetosuggestthatmorphinecanaggravateorcausepancreatitis.3.Repeateddosesofmeperidinecanleadtoaccumulationofthemetabolitenormeperidinethatcausesneuromuscularirritationand,rarely,seizures.Morphinemaybeofmorebenefitthanmeperidinebyofferinglongerpainreliefwithlessriskofseizures4.Intravenousmetamizoleshowsanon-significantassociationwithaquickerpainreliefthanmorphines.c.inacutepancreatitis.Alargerrandomizedcontrolledtrialshouldbedesirabletoconfirmthisresult.結論1.Meperidine

hastraditiona36如何應用於臨床？1.沒有強力証據顯示Demerol比morphine好2.使用Demerol需小心seizure的風險3.Metamizole也許是臨床上更好的選擇,仍需更多RCT如何應用於臨床？1.沒有強力証據顯示Demerol比morp37困境或陷阱目前仍無強力RCT證明何者為佳需要更多Trial困境或陷阱目前仍無強力RCT證明何者為佳38參考資料：證據的強度參考資料：證據的強度39參考資料：證據等級和臨床建議GradeofRecommendationLevelofEvidenceTherapy[A]1aSystemicreviewofRCTs1bSingleRCT1c‘All-or-none’[B]2aSystemicreviewofcohortstudies2bCohortstudyorpoorRCT2c‘Outcomes’research3aSystemicreviewofcase-controlstudies3bCase-controlstudy[C]4Caseseries[D]5Expertopinion,physiology,benchresearch參考資料：證據等級和臨床建議GradeofRecomme40參考資料參考資料41實證醫學競賽－CAT摘要組別：第(A)組實證醫學競賽－CAT摘要42訂定PICOP:acutepancreatitiswithabdominalpainI:gabexatemesilateC:placeboO:complication,mortality,morbidity,abdominalpain訂定PICOP:acutepancreatitisw43資料庫來源PubmedCochraneUptodate資料庫來源Pubmed44搜尋之關鍵字請列出你們用了哪些關鍵字。搜尋之關鍵字請列出你們用了哪些關鍵字。45搜尋之歷程請列出你們搜尋的歷程。搜尋之歷程請列出你們搜尋的歷程。46文獻研讀請列出你們認為證據最強的相關文獻一至三篇針對每篇文獻，請摘錄其：題目及出處(e.g.Dosingandsafetyofcyclosporineinpatientswithseverebraininjury.JNeurosurg.2008;109(4):699-707)研究設計(studydesign)結果(若有計算NNT、RR、OR等，請一併列出)證據等級(levelofevidence)文獻研讀請列出你們認為證據最強的相關文獻一至三篇47第一篇Prospectiveandrandomizedstudyofgabexatemesilateforthetreatmentofsevereacutepancreatitiswithorgandysfunction.(Hepatogastroenterology.2000Jul-Aug;47(34):1147-50)METHOD:52patientswithacutepancreatitisandorgandysfunctionwereenrolled.Thetreatmentgroupincluded26patientsreceivingintravenousgabexatemesilateinfusionatadoseof100mg/hrfor7days.APACHE-IIscore,clinicalandbiochemicalparametersweremonitoredintensively.CONCLUSION:Coagu