David Eddy, one of the founders of evidence-based medicine, is a famous American expert in evidence-based medicine. He was first author on a key article in JAMA in 1990 and coined the term "evidence-based". He made great contributions in medical decision making, applied mathematics, health economics and devoted himself to the establishment and dissemination of evidence-based guidelines. In this article, the process of his striving and academic research is introduced and his unique insight into and new interpretion of evidence-based medicine are elaborated.
Objective To evaluate the effectiveness and safety of different injection sites for collagenase chemonucleolysis for lumbar intervertebral disc protrusion (LIDP). Methods We searched for randomized controlled trials (RCTs) and quasi-RCTs in the following electronic databases: Pubmed (1966 to May 2006), EMBASE(1966 to May 2006), The Cochrane library (Issue 2, 2006), CRD(Center for Reviews and Dissemination),York University, CBM (1978 to May 2006 ), CNKI(1994-2006)and VIP(1989-2006). Quality assessment and data extraction were conducted by two reviewers independently. Disagreement was resolved through discussion. Results Eight studies involving a total of 1035 participants met the inclusion criteria. Meta-analysis was not carried out because of apparent heterogeneity. Four studies made comparisons among intradisc, extradisc, and combined intra- and extra-disc injection. One study (62 participants) showed that intradisc injection was superior to extradisc injection (RR 3.71, 95% CI 1.19 to 11.58, Plt;0.05). Another study (240 participants) showed that intradisc injection was superior to combined intra- and extra-disc injection after 3 months and 6 months of follow-up (RR 0.88, 95% CI 0.80 to 0.98, Plt;0.05). The other two studies showed no significant difference among intradisc, extradisc, and combined intra- and extra-disc injection. Four studies (436 participants in total) showed that amongst three extradisc injections, both anterior epidural space injection and lateral epidural space injection were superior to posterior epidural space injection (Plt;0.05). Although one study indicated that anterior epidural space injection was superior to lateral epidural space injection (RR 1.24, 95% CI 1.03 to 1.51, Plt;0.05), no statistical significance was found between anterior epidural space injection and lateral epidural space injection in two other studies (Pgt;0.05). Conclusions There is insufficient evidence to identify which injection site for collagenase is the most effective for lumbar intervertebral disc protrusion. The included studies showed that both anterior and lateral epidural space injection were superior to posterior epidural space injection. However, these studies are too small and poor quality, and have different diagnostic criteria, follow-up time points, outcome measures and efficacy parameters. Thus, more high quality and large-scale RCTs are needed.
ObjectiveTo evaluate the usefulness of estimation of physiologic ability and surgical stress (E-PASS) for predicting postoperative complications in patients undergoing elective colorectal cancer surgery. MethodsPatients underwent colorectal cancer surgery between August 2009 and October 2010 were analyzed retrospectively. E-PASS equations were applied to those patients for estimation of operative risk. The preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) of the E-PASS were compared with actual postoperative complications. The relationship between E-PASS variables and morbidity after colorectal cancer surgery was identified. ResultsOf the 313 patients, 22 (7.0%) had postoperative complications. Of all the E-PASS variables between complicative group and noncomplicative group, the morbidity was significantly correlated to age (P=0.003), weight (P=0.019), tumor histologic types (P=0.033), Dukes stage (P=0.001), severe heart disease (P=0.019), severe pulmonary disease (P=0.000), performance status (P=0.000), loss of blood volume/body weight (P=0.007), loss of blood volume (P=0.001) and operation time (P=0.001). Differentiation degree of tumor (P=0.503), diabetes (P=0.745), ASA grade (P=0.085), and size of surgical incision (P=0.726) were not significantly associated with postoperative complications. The PRS and CRS were higher in complicative group than those in noncomplicative group (Plt;0.001). But the difference of SSS between the two groups was not statistically significant (P=0.059). ConclusionThe E-PASS scoring system is a relatively simple, fast, and operable tool that can be used to predict short-term postoperative morbidity accurately for clinical decision-making in colorectal cancer surgery.
Objective In light of problems related to the accessibility and affordability of healthcare, we aimed to investigate the status and causes for the shortage of qualified health human resources in the rural and primary health care setting, and to propose solutions to these problems at the level of health policy system. Methods The principles and methods of evidence-based medicine were applied. We developed the study selection criteria on the basis of the proposed questions, and identified relevant literature from biomedical databases and other additional sources. We graded eligible studies, extracted data, and summarized the data to draw conclusions. In addition, we conducted a survey to refine the proposed solutions. Results We identified 147studies from PubMed and CNKI, of which 30were in English. After summarizing the information, and using knowledge about the human resources for health in primary healthcare in China, we proposed a model of resident doctor aid healthcare. The survey that we conducted to assess such a model included interviewees of top level policy makers, medical students and staff in medical universities. Most of the interviewees (85%) thought it was feasible to develop an aid healthcare system. Among those who disagreed, the lack of corresponding policy was the most common factor. Conclusions It is suggested that the government develop relevant policies and make an attempt to practice the aid healthcare system. Emerging problems could be identified and addressed in practice.
Objective To investigate the effects of two formulations of artesunate, and to provide evidence for the WHO Model List of Essential Medicines. Methods We searched The Cochrane Library (2006, Issue 4), MEDLINE ( 1966 to 2007), EMbase (1988 to 2007), CBM (1978 to 2007), VIP (1989 to 2007) and CNKI (1994 to 2007). Randomised trials comparing the two formulations of artesunate with other drugs were eligible for inclusion. We applied the methods of The Cochrane Collaboration to assess the effects of artesunate, compared to placebo and active controls. Results Eleven trials were included, of which 6 compared intravenous artesunate with intravenous quinine. The quality of each study was high, 6 out of the 11 studies were graded A according to the criteria of The Cochrane Collaboration. The other 5 were graded B. The meta-analysis suggested that the mortality rate was lower in the intravenous artesunate group than in the intravenous quinine group [RR 0.65, 95%CI (0.52, 0.80), Plt;0.0001]. Three trials compared intravenous artesunate with artemisinin suppositories. These trials generated similar estimates and confidence intervals for mortality rates, showing no significant difference between the two treatments [0.94 (0.35 to 2.56), 0.58 (0.19 to 1.74) and 2.00 (0.39 to 10.26)]. Two trials compared intravenous artesunate and intramuscular artesunate, and no significant difference in mortality rate was identified between the two treatment groups [RR 1.50, 95%CI 0.52 to 4.31]. Mortality rates were not statistically significantly different for intravenous artesunate compared to alternative drugs. No significant adverse drug reactions were observed. Conclusions Artesunate is effective and safe in the treatment of severe malaria.
Objective To assess the effectiveness and safety of combination therapy of zidovudine and lamivudine (ZDV+3TC) for preventing mother-to-child transmission (MTCT) of HIV. Methods A systematic review of randomized controlled trials (RCTs) was conducted using the methodology of The Cochrane Collaboration. PUBMED, EMBASE, CINAHL, AIDSearch, AIDSLINE, AIDSTRIALS, The Cochrane Library (Issue 2, 2007), AIDSDRUGS, AIDSinfo, CRD (Center of Review and Dissemination) databases and three Chinese Databases (CBM, CNKI, VIP) were searched from their establishment to 31 May 2007. We also searched documents of governmental and non-governmental organizations (NGOs), and the proceedings of relevant conferences, including the International AIDS Conferences, and the annual Conference on Retroviruses and Opportunistic Infections. RCTs assessing the effects of ZDV+3TC for preventing MTCT were included. Trial selection, quality assessment and data extraction were done by two reviewers independently. Different opinions were resolved by discussion with a third party. Meta-analyses were conducted using The Cochrane Collaboration’s RevMan 4.2.9 software. Results Three studies in breastfeeding populations were included. One trial (PETRA, 1797 participants) found that ZDV+3TC decreased the risk of transmission by 35%-65% within 15 months compared with placebo. However, there was no evidence that ultra-short course ZDV+3TC (during labor) decreased the risk of transmission, compared with placebo. The safety of different courses of ZDV+3TC and placebo were similar (Pgt;0.05). Another trial (SAINT, 1317 participants) found that short course ZDV+3TC (from 36weeks gestation to labor) did not significantly reduce HIV infection among children at 8 weeks after delivery, when compared with single dose nevirapine given to the mother and the infant (Pgt;0.05). No significant difference was found in the maternal and infants mortality and side effects of two groups. One small trial (Moodley1998, 20 participants) found no infant infection in both ZDV+3TC and 3TC alone within 2 weeks after birth. Conclusions Long course (from 36 weeks gestation to 1 week after delivery) and short course (from 36 weeks gestation to labor) ZDV+3TC were more effective than placebo in preventing MTCT of HIV in breastfeeding women with a similar safety profile. Short course ZDV + 3TC had similar effects to single dose nevirapine, and long course ZDV + 3TC had similar effects to lamivudine alone.
目的 系統評價單獨應用齊多夫定（zidovudine，ZDV）阻斷HIV母嬰傳播的有效性和安全性。方法 采用Cochrane系統評價方法，計算機檢索Cochrane圖書館（2007第1期）、PubMed、EMbase、CINAHL、AIDSearch、AIDSLINE、AIDSTRIALS、AIDSDRUGS、AIDSinfo、CRD（center of review and dissemination）、CBMdisc，VIP和CNKI等數據庫，以及全球或地區性AIDS相關的會議論文集、政府或非政府組織的相關文件等，檢索日期截至2007年4月30日，全面收集全球抗艾滋病病毒藥物預防HIV母嬰傳播的隨機對照試驗。由兩名評價員獨立篩查文獻、評價質量和提取資料，然后交叉核對，若遇分歧則征求第三方意見討論解決。使用RevMan軟件進行Meta分析。結果 共納入8個RCT，包括24篇全文和13篇摘要，其方法學質量的Jadad評分≥3分。Meta分析顯示：① ZDV與安慰劑比較共納入4個RCTs（2385例），無論長短療程、母乳或非母乳喂養人群，ZDV預防HIV母嬰傳播的效果均優于安慰劑組，降低HIV母嬰傳播風險43%～50%，且兩組死產率、嬰兒死亡率、母親死亡率、早產、低體重兒、出生缺陷、母嬰不良反應發生率和母親產前、產時和產后并發癥發生率差異均無統計學意義（Pgt;0.05）。② 1個大樣本RCT（1437例）比較了ZDV不同療程的效果，結果顯示ZDV“長–長療程”（從孕28周開始到產后6周）比“短–短療程”（從孕35周開始到分娩后3天）降低HIV母嬰傳播風險61%［RR=0.39，95%CI（0.19，0.82）］。長–長療程與長–短療程（從孕28周開始到產后3天）及短-長療程（從孕35周開始到產后6周）比較，其預防HIV母嬰傳播的效果差異均無統計學意義（P gt;0.05）。各組死產、新生兒死亡、1年內嬰兒死亡、母親死亡、早產、低體重兒、出生缺陷、母嬰不良反應發生率相似（Pgt;0.05）。③ 1個大樣本RCT（1 200例）顯示：人工喂養+短程ZDV預防HIV母嬰傳播的效果優于母乳喂養+長程ZDV，可降低嬰兒HIV感染風險的35%～39%，但提高了嬰兒7個月時的死亡率（9.3% vs 4.9%；P=0.003）；兩組嬰兒早產率、低體重兒出生率、出生缺陷率、不良反應發生率相似（Pgt;0.05）。④ 2個直接比較短程或超短程ZDV與單劑量奈韋拉平（Nevirapine，NVP）預防HIV母嬰傳播效果的RCT（702例）顯示，NVP可降低HIV母嬰傳播風險的44%～48%，兩組死產、6月內嬰兒死亡、母親死亡、低體重兒、母嬰不良反應發生率相似（Pgt;0.05）。結論 無論長短療程、母乳或非母乳喂養人群，ZDV預防HIV母嬰傳播的效果均優于安慰劑，且其妊娠結局和不良反應發生情況相似。ZDV“長–長療程”比“短–短療程”預防HIV母嬰傳播效果更好，但長–長療程與長–短療程、短–長療程預防HIV母嬰傳播的效果相似；各組安全性相似。人工喂養+短程ZDV預防HIV母嬰傳播的效果優于母乳喂養+長程ZDV，但提高了嬰兒7個月時的死亡率。單劑量NVP預防HIV母嬰傳播效果優于短程和超短程ZDV，且安全性相似。
Objective To provide baseline data for the Special Healthcare Program of Comprehensive Reform for Coordinated and Balanced Urban-rural Development in Chengdu. Methods We selected 7 township/community health institutions and 6 village health posts /street clinics using stratified sampling to take account of the levels of economic development and the distance from the centre of Chengdu We then performed on-site surveys and secondary research. Data were analyzed by using Epidata or Excel. Results The utilization of health institutions was generally good. The number of visits and number of inpatients in medical institutions increased steadily. The utilization rate of hospital beds and doctors’ workload were higher than the national average. The average medical expense per outpatient /inpatient was far lower than the national level. The overall condition of the health institutions that close to the centre of Chengdu was better. Conclusion We should persist in taking advantage of the rural hospitals’ construction to improve village health posts /street clinics and strengthen the national and governmental compensating mechanism for township /community health organizations (village health posts /street clinics), so as to make the basic condition of current township/ community health organizations (village health posts /street clinics) better.
Objective To investigate human resource allocation in primary health care and the essential medical service and publ ic health service status in urban and rural areas in Chengdu, so as to provide basel ine data for the Special Healthcare Program of Comprehensive Reform for Coordinated and Balanced Urban-Rural Development in Chengdu. Methods We carried out a stratified (three circles in Chengdu) sampl ing of 7 township hospitals (rural hospitals) and community health service centers; and then performed secondary research based on a comparative analysis of relevant pol icies of the World Health Organization (WHO) and Chinese governments at all levels. Results According to the WHO and national average standards, the number of staff per 1 000 rural hospitals / centers health personnel of the 7 rural hospitals / centers occupied only 1%-22% of the global average standard. There was a very large gap between the number of staff and the number of personnel required, based on the size of the population that should be served in the administrative areas in 2006 or the number of cl inic patients in 2006. The primary healthcare personnel structure was irrational. For example, the constituent ratio of health technical personnel was 4% to 33% higher than the global average level, and the constituent ratio of (assistant) physicians was also 17% to 45% higher than the global average level. However, the ratio of nurses, laboratory workers, other health professionals, administrative and supporting personnel was generally lower than the global average level. Women dominated among the primary healthcare personnel, and people aged 45 years or below counted for more than 75% (except Bailu and Wangjiang rural hospitals/centers). People with an educational background of two-year college education or secondary education or below took up 70% to 90%; while those with an intermediate title or assistant /primary title accounted for 50% to 100%. The structure rational ity of distribution density, educational background and academic titles of healthcare personnel showed a decreasing trend from the first circle to the third circle in Chengdu city. Conclusion The primary health workers in the second and third circle have been overloaded with low incomes for some time. They are facing enormous challenges in their professional skills, service awareness, as well as difficulties in continuing education and professional title promotion. It is very difficult to provide qual ified "six in one" primary health care and publ ic health services in a long-term and stable manner. It is suggested that we enroll and train more skilled people for primary health care service, and provide continuing education chances for current health care personnel. We should also adopt a mechanism to select qual ified personnel based on their performance, and take measures to solve some of the problems faced by the grass-root health personnel, such as heavy work burden, low income, poor skill and promotion. This will help us to construct a stable and qual ified primary healthcare team.
Objective The Chengdu initiative essential medicine policy is part of the Special Healthcare Program of Comprehensive Reform for Coordinated and Balanced Urban-rural Development. We aimed to investigate the current situation of medicine use in rural hospitals and community health service centers, so as to provide evidence for policy-makers to select essential medicines and facilitate rational use of medicines. Method We selected 7 township/community health institutions from which to collect medicine use information, including medicine category, number of medicine categories, cost and consumption. Descriptive analysis and the ABC classification method were applied for statistical analysis. Results The number of medicine categories used in the community health institutions was four times greater than that in the township health institutions. Traditional Chinese medicine preparations accounted for 40% of the total medicine cost. Polypharmacy, overuse of injections, and improper use of antibiotics were major manifestations of the irrational use of medicines. Conclusion The selection and use of essential medicines should be base on high quality evidence as well disease burden, the economic situation and specific demands in different areas. Drug and therapeutics committees should be set up to perform dynamic monitoring, education, evaluation and continual improvement of an essential medicines list.