病因学及危险因素-循证医学.ppt

病因危险因素分析与评价对循证诊治的重要性 根据真实性的病因证据采用特异性干预 HIV与AIDS 乙肝病毒与肝炎 常用的因果推断标准 关联的时间顺序 关联的强度 关联的可重复性 关联的合理性 剂量-反应关系 暴露与疾病分布的一致性 研究的因果论证强度 不同结果的重要性 阳性的真实性证据 阳性的真实性证据，则可用于指导预防决策。如：HBV导致肝癌，则开展了HB疫苗的预防接种和加强HB的早诊早治以改善预后，预防肝癌。 阴性的真实性证据 当研究否定了可以病因/危险因素致病的因果效应时，则有利于及时调整错误的防治决策。如：随机对照试验，证实了更年期妇女补充雌激素，对预防心脑血管疾病无效，因而可否定这一预防措施。 Study design (1): a parallel-group, randomized, controlled trial involving adult medical and surgical patients admitted to the ICUs of 42 hospitals: 38 academic tertiary care hospitals and 4 community hospitals, Australia, New Zealand, and Canada. Eligible patients were those expected to require treatment in the ICU on 3 or more consecutive days Intensive: 81~108 mg /dl (4.5~6.0 mmol/L) Conventional: =180 mg/dl (=10.0 mmol /l) Finfer S, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97. Study design(2) Randomization was stratified according to type of admission (operative or nonoperative) and region (Australia and New Zealand or North America). The treatment assignments were concealed before randomization, but subsequently, clinical staff were aware of them. Control of blood glucose: insulin Conventional: insulin, if glucose =180mg/dl; discontinued, if glucose 144 mg /dl The trial intervention was discontinued once the patient was eating or was discharged from the ICU but was resumed if the patient was readmitted to the ICU within 90 days. It was discontinued permanently at the time of death or 90 days after randomization, whichever occurred first. Outcomes Primary outcome measure was death from any cause within 90 days after randomization, in an analysis that was not adjusted for baseline characteristics. Secondary outcome measures were survival time during the first 90 days, cause-specific death, and durations of mechanical ventilation, renal-replacement therapy, and stays in the ICU and hospital. Tertiary outcomes were death from any cause within 28 days after randomization,