循證醫(yī)學(xué)實(shí)踐案例分析

1、循證醫(yī)學(xué)實(shí)踐教學(xué)案例分析科別:口腔頜面外科住院號(hào)：38871入院日期:2014.1.6報(bào)告者姓名:張夢(mèng)涵職務(wù)：口住院醫(yī)師基地醫(yī)師實(shí)習(xí)醫(yī)師完成時(shí)間:2014.3.3病例摘要患者牛某，女性，15歲主訴：左側(cè)下唇麻木五月余，正畸拍片發(fā)左側(cè)下頜骨病變?nèi)觳±攸c(diǎn)：患者五個(gè)月前自覺(jué)左側(cè)下唇麻木，未予重視?；颊哐懒胁幻烙^，三天前于塘沽口腔 醫(yī)院正畸科就診時(shí)拍攝曲面斷層片發(fā)現(xiàn)左側(cè)下頜骨病變，建議轉(zhuǎn)院治療。今來(lái)我院就診，門診 查體后以左側(cè)下頜骨腫物收治入院。患者發(fā)病以來(lái)，精神狀態(tài)良好，飲食二便如常，體重?zé)o 明顯減輕。既往史：無(wú)。查體:BP : 90/60mmHg，P ： 78次/分，R ： 19次/分，T :

2、 36.1攝氏度。頜面部外形基本對(duì)稱， 開(kāi)口度3.7cm，開(kāi)口型正常，口內(nèi)左側(cè)下頜骨頰側(cè)可捫及一直徑約2.0cm大小類圓形骨性膨隆， 乒乓球樣感不明顯，無(wú)壓痛，黏膜無(wú)異常，下頜骨舌側(cè)未觸及明顯骨性膨隆。左側(cè)下唇麻木， 左側(cè)下頜牙齒牙體牙周情況良好。頦下、頜下及頸部未觸及腫大淋巴結(jié)。輔助檢查：血常規(guī)：中性粒細(xì)胞比率37.7%，淋巴細(xì)胞比率55.81% ；生化常規(guī)示：丙氨酸氨基 轉(zhuǎn)移酶310U/L，堿性磷酸酶184U/L，總膽汁酸13.35mmol/L，天冬氨酸氨基轉(zhuǎn)移酶58U/L ；天津 市口腔醫(yī)院拍攝頜面部CT示：左側(cè)下頜骨可見(jiàn)一單房囊性陰影，邊界清晰，前至33遠(yuǎn)中，后 達(dá)升支前緣，病變舌側(cè)膨

3、隆較頰側(cè)明顯，舌側(cè)骨質(zhì)部分缺失，內(nèi)部密度均勻，病變內(nèi)未見(jiàn)明顯 骨間隔，34、35、36、37牙根位于病變內(nèi)，牙根無(wú)明顯吸收。腫物穿刺液菌培養(yǎng)；甲型溶血性 鏈球菌。診斷：左側(cè)下頜骨腫物成釉細(xì)胞瘤治療方式：初步排除手術(shù)禁忌證后，全麻下行下頜骨腫物切除術(shù)。后續(xù)治療：術(shù)中見(jiàn)腫物為色白、實(shí)性，病理回報(bào)成釉細(xì)胞纖維瘤，影像學(xué)提示病變范圍大，需 手術(shù)擴(kuò)大切除，游離髂骨修復(fù)頜骨缺損。全麻下行下頜骨腫物擴(kuò)大切除術(shù)，下頜骨部分切除術(shù)， 游離髂骨切取術(shù)，下頜骨重建術(shù)，頜骨單頜固定術(shù)，鄰近皮瓣轉(zhuǎn)移修復(fù)術(shù)，牙齒拔除術(shù)。提出可回答的臨床問(wèn)題(Asking)P:成釉細(xì)胞瘤患者I：下頜骨腫物切除術(shù)C:下頜骨腫物擴(kuò)大切除術(shù)加游

4、離骼骨移植術(shù)O:切除腫物，防止復(fù)發(fā)，修復(fù)面型檢索最有用的證據(jù)(Acquire)關(guān)鍵詞(Key word )： ameloblastoma， iliac bone grafts數(shù)據(jù)庫(kù)來(lái)源(Database )： PubMed Clinical Queries主要內(nèi)容： Nonvascularized iliac bone grafts for mandibular reconstruction-requirements and limitations.AbstractBACKGROUND: Treatment of intraoral malignant tumors often leads t

5、o continuity defects of the mandible. Whereas the use of free vascularised flaps has shortcomings regarding donor site morbidity and a worse-fitting bone geometry, the nonvascularized iliac crest graft could be an alternative option. The purpose of this study was to describe the treatment outcome wi

6、th nonvascularized iliac crest grafts over a 10-year period and to determine possible limitations of their use.PATIENTS AND METHODS: Eighty-four patients with bicortical nonvascularized iliac crest grafts for mandibular reconstruction were examined at least one year after reconstruction. Patients re

7、cords and the radiological and/or surgical data were analyzed.RESULTS: Sixty-three patients (75%) showed complete healing, in 20 patients the treatment was not successful and in one patient the treatment result was unclear. Interestingly, comparing the successfully and the unsuccessfully treated pat

8、ients, only the irradiation dose played a crucial role. Neither defect length nor defect localisation, nor time interval between resection and reconstruction were statistically significant parameters in graft success. Comparing only patients with malignancies, the non-irradiated patients had a highe

9、r success rate (77.3%).CONCLUSION: The nonvaslcularized iliac crest graft seems to be a reasonably reliable treatment option for reconstruction of mandibular defects up to about 5-6 cm in size. Radiotherapy is a strong confounder reducing the success rate. Necessary constraints are sufficient soft t

10、issue conditions. However, primary reconstruction by free flaps (e.g. fibula flap) has a higher success rate in literature and should be preferred whenever possible.證據(jù)評(píng)價(jià)(Appraisal )證據(jù)等級(jí)：DWorksheetScreening Questions1. Did the study ask a clearly-focused question? Yes Cant tell NoConsider if the ques

11、tion is focused in terms of:-the population studied-the intervention given一 the outcomes considered2. Was this a randomised controlled trial (RCT) Yes Cant tell Noand was it appropriately so?Consider:一 why this study was carried out as an RCT-if this was the right research approach for thequestion b

12、eing askedIs it worth continuing?Detailed Questions3. Were participants appropriately allocated to Yes Cant tell Nointervention and control groups?Consider:一 how participants were allocated to intervention and control groups. Was the process truly random?-whether the method of allocation wasdescribe

13、d. Was a method used to balance the randomization, e.g. stratification?-how the randomization schedule was generated and how a participant was allocated to a study group-if the groups were well balanced. Are any differences between the groups at entry to the trial reported?一 if there were difference

14、s reported that might have explained any outcome(s) (confounding)8. How are the results presented and what is the main result?Consider:-if, for example, the results are presented as a proportion of people experiencing an outcome, such as risks, or as a measurement, such as mean or median differences

15、, or as survival curves and hazards-how large this size of result is and how meaningful it is-how you would sum up the bottom-line result of the trial in one sentence9. How precise are these results?Consider:-if the result is precise enough to make a decision-if a confidence interval were reported.

16、Would your decision about whether or not to use this intervention be the same at the upper confidence limit as at the lower confidence limit?一 if a p-value is reported where confidence intervals are unavailable10. Were all important outcomes considered soYes Cant tell Nothe results can be applied?Co

17、nsider whether:-the people included in the trail could be different from your population in ways that would produce different results一 your local setting differs much from that of the trial一 you can provide the same treatment in your settingConsider outcomes from the point of view of the-individual一

18、 policy maker and professionals一 family/carers一 iv/der communityConsider whether-any benefit reported outweighs any harm and/or cost. If this information is not reported can it be filled in from elsewhere?-policy or practice should change as a result of the evidence contained in this trial Public Health Resource Unit, England (2GO6). All rights cessed證據(jù)解讀及證據(jù)應(yīng)用