@LIVES 2015 year in review 2
Ten things you should consider before you believe a clinical practice guideline
http://bit.ly/1CigGER
1.
A CPG has to be reasonably current, and the definition of ‘reasonably current’ seems to change. Published in 2013 [1], the Surviving Sepsis Campaign (SSC) guidelines dealing with resuscitation algorithms, resuscitation fluids or transfusion in patients with sepsis did not consider a number of studies and meta-analyses published subsequently [2, 3]. These recommendations may need revision even before the next ‘full text’ is published––a 4-year hiatus between editions seems increasingly inadequate. Ongoing electronic updates, often referred to as living guidelines, are likely coming our way.
2.
The clinical questions have to be specific enough to deliver practical and actionable answers. To this end, we suggest they follow the PICO format for Population, Intervention, Comparator, and Outcome. The next three points deal with the choice of population, comparator, and outcome.
3.
Specific questions have to take into account the ‘age of the evidence.’ Recommendations regarding the use of beta blockers at the time and following myocardial infarction may well need to rely on data emerging from randomized studies performed in the current reperfusion era with possibly little emphasis on older randomized studies as the number of new co-interventions used in both groups might have a modifying effect [4].
4.
The interventions and comparator should be clinically relevant. A comparison of all colloids to all crystalloids in the setting of sepsis make little sense in light of the realization that not only all colloids—but also all crystalloids—are not created equal [5, 6].
5.
The outcomes assessed in judging the benefits should be patient-important outcomes as opposed to convenient surrogate or substitute endpoints. Improvement in cardiac output, urine output, central venous pressure, and/or peak flows may suggest possible benefit. Unfortunately, apparently beneficial changes in surrogate outcomes have very often been associated with lack of benefit in patient-important outcomes and—not infrequently—in harm [7]. Diagnostic technologies may provide similarly misleading results: knowledge, or the impression of knowledge, does not always translate into patient benefit (most of us remember the widespread use of right heart catheters which likely had no benefit and possibly did more harm than good) [8, 9].
6.
As undesirable effects are unavoidable, guidelines should clearly and comprehensively present both the desirable and undesirable consequences of the recommended courses of action in an easy-to-access and easy-to-understand format [10]. Those estimates should be based on systematic reviews and should be clearly linked to the recommendations which are using them as justification.
7.
These estimates of effect may be more or less trustworthy. Guidelines should make the certainty of the evidence (also known as confidence in the estimates or quality of the evidence) explicit, clearly presenting the degree of confidence (from highly confident to poorly confident) associated with the evidence [11].
8.
Guidelines should clearly distinguish between recommendations that apply to virtually all patients in all circumstances and those in which alternative courses of action are both reasonable and may—in specific circumstances—be preferable. The former, strong recommendations are usually based on at least moderate certainty of treatment effects AND a decisive balance in favor of beneficial effects of intervention. Guidelines typically offer weak recommendations when intervention effects are uncertain OR there is high certainty of the estimates, but the balance between desirable and undesirable outcomes is close. The judgments underlying decisions, especially controversial ones, should be explicitly acknowledged [12].
9.
CPGs should provide an account of how the conflict of interest (COI) was addressed. Simple disclosure is unlikely to be sufficient. Active interventions to decrease the possibility of both financial and academic COIs are being increasingly recognized as needed [13, 14].
10.
Lastly, authors of CPGs should make it clear that they do not wish to generate uniform practice for all patients and all clinicians, but rather provide background information and some wider judgments necessary to make decisions. The individual decisions should then account for individual patient’s values and preferences and idiosyncratic clinical specificities. Authors should stress the non-dogmatic character of the majority of recommendations, especially those based on low certainty of effects or those associated with a close balance between harms and benefits. However, even strong recommendations should leave room for patient-specific flexibility. After all, this is all about guidance not forced uniformity [15].
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「conflict definition」的推薦目錄:
conflict definition 在 CUP 媒體 Facebook 的最佳解答
//I wonder if, before they put their names to the letter, anyone told the 700 signatories that twice already – once in 2000 and once in 2008 – Israel offered the Palestinians the chance to build an independent state on over 90% of the territories, and on both occasions the Palestinians refused?
Do they know that Gaza is ruled by Hamas, a terrorist organisation that punishes homosexuality with hanging? That severely restricts the freedom of women to do such dangerous things as running a marathon or riding a scooter? Where Jews and Christians don’t have the right to live?
Maybe when they aren’t signing petitions they would prefer democratic regimes, like Israel, where there is freedom of expression and freedom of the press and where rights for the LGBT community are protected by law. Where Muslims and Christians serve in the supreme court, the Knesset and senior positions in the military; where women have served as prime minister, as president of the supreme court and in the highest ranks of the army?
As artists – who by definition are people with imagination – are they willing to take a moment and consider this: let’s imagine that following a call in the Guardian the IDF puts down its weapons and stops protecting the people of Israel for 24 hours – what do they think would happen?
If you don’t share the imagination of an artist let me tell you: radical Islamists would kill us all. Women and children first. That’s what they’re doing to their brethren in Syria, Iraq, Afghanistan, Yemen and across the Islamic world. What are the chances that they’d spare us?
To end the conflict Israel only has one demand: security for our citizens. We don’t believe that’s unreasonable. In 2005, as part of the disengagement from Gaza, Israel pulled out without any demands from Gaza, took down the settlements and removed the army from the area.
We expected the Palestinians would take the opportunity to build schools, hospitals and factories but instead they kicked out the Palestinian Authority from Gaza and brought in Hamas – a fundamentalist Islamist terror group of the worst kind. And after a few months they began building terror tunnels into Israeli territory and started massive rocket and mortar fire upon the innocent civilian population.//
conflict definition 在 Eric's English Lounge Facebook 的最佳貼文
[學生常犯的寫作錯誤1]
學習者應該怎麼修正自己的錯誤?
https://www.dropbox.com/s/l7w3d0c7xmam0lw/AWFAQ2.pdf?dl=0
1. He can’t leave early because he has many works to do. [X]
He can’t leave early because he has a lot of work to do. [O]
He can’t leave early because he has many projects to do. [O]
解釋: work 當工作時是不可數名詞,只有當藝術,文學,和音樂的作品時才可數 (works of art)。
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2. Reading daily helps people learn a lot of knowledge. [X]
Reading daily helps people acquire a lot of knowledge. [O]
解釋: learn 是學習而 knowledge 是知識,學問。你只可以獲得知識而不是學習知識。
請多參考配詞辭典: http://www.ozdic.com/collocation-dictionary/knowledge
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3. About a million people in the region are lack of drinking water because of a prolonged drought. [X]
About a million people in the region lack of drinking water because of a prolonged drought. [X]
About a million people in the region lack access to drinking water because of a prolonged drought. [O]
Where there is a lack of water, there is conflict. [O]
Reports of the drought and exactly what is happening are lacking. [O]
The new government is lacking in experience. [O]
解釋: 在這裡 lack是一個及物動詞,所以可直接接受詞。補充:當lack是名詞時,則必須用of (lack of water = 名詞片語) 。Lacking是形容詞,使用時可以加入介係詞 in 來連接名詞。
http://www.oxforddictionaries.com/definition/american_english/lack?q=lack
http://www.oxforddictionaries.com/definition/american_english/lacking?q=lacking
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4. Many people choose not to attend the university after high school. [X]
Many people choose not to attend university after high school. [O]
解釋: 在表示處於某種狀態或從事某種活動的抽象概念時不用定冠詞the,指定哪一所大學時才會在這裡用定冠詞。
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5 A list of names and numbers are on the table. [X]
A list of names and numbers is on the table. [O]
解釋:主詞後面的介系詞片語,只作修飾用,因此一致性只需看名詞的部分。
The country's leading export are cameras. [X]
The country’s leading export is cameras. [O]
解釋: be 動詞要和它的主詞一致,和補語無關,不要被混淆了!
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6. Steve Jobs, the former CEO of Apple, has died for almost three years. [X]
Steve Jobs, the former CEO of Apple, has been dead (adj.) for almost three years. [O]
Steve Jobs the former CEO of Apple, passed away (euphemism--婉轉說法) three years ago. [O]
解釋: 中文裡沒有「動作動詞」與「狀態動詞」的區分,不論是解釋動作或狀態往往都用同一個字詞來表示,但是在英文書寫時就容易出問題了。上列的句子皆是表示動作發生之後的某種狀態,所以不能再用”動作動詞”來描述,應該用”狀態”來表達。
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7. The students forget to bring their homework assignments to school today. [X]
The students forgot to bring their homework assignments to school today. [O]
解釋:現在式表示「事實」,但當在敘述你忘記某件事情時,因為你是在”過去”忘記這件事,所以用過去式。
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8. He becomes an excellent student after a sincere talk with his teacher. [X]
He became an excellent student after a sincere talk with his teacher. [O]
解釋: “他變成了一個好學生…”這是表示明顯改變的動詞。因為是敘述過去的改變,所以要用過去式。
(改變-become是在講這句話之前就已經發生的事,所以用過去式,但如果要說他現在是一位好學生,直接用He is an excellent student來表示)
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9. The ambassador answered the difficult question with warmth and in a humorous way. [X]
The ambassador answered the difficult question with warmth (n.) and humor (n.). [O]
解釋: 為了要表達一些地位平等的想法,英文使用平衡結構 (Parallelism),將兩個字詞或句子用以下幾種方式連接起來,所連接的兩邊要使用一樣的時態、詞類等,以求平衡。
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10. People should stop to smoke as soon as possible. [X]
People should stop smoking as soon as possible. [O]
解釋:句子要表達的是人應該停止抽菸。由於把抽菸當作一件具體的事件,所以應該使用動名詞,若使用不定詞,則代表人應該停下來去抽菸。
Common Writing Errors [學生常犯的寫作錯誤]
I. https://www.dropbox.com/s/rm0lxlbo1cdj9dn/CEI.pdf
II. https://www.dropbox.com/s/88vl5h6tbud4cm4/CE2.pdf
III. http://tinyurl.com/mq2n234
IV. http://tinyurl.com/jwhm6f3