臨床場景 (Clinical Scenario)

1. 臨床場景(Clinical Scenario) 問題 Ask 60 y/o女性農婦，20歲結婚後就跟著先生經營農場，主要種植柑橘和玉米。平時身體狀況不錯，只是血中尿酸自30歲起就發現一直在9.0以上，因為沒有症狀所以一直不管它。10年前開始左大腳趾關節腫痛過幾次，每次吃個3天普拿疼後都會好。5年前開始兩個膝蓋開始有酸痛現象，因此就不再從事搬運農作物的工作，但仍然每天去巡視農場。最近因右膝疼痛越來越厲害，影響走路而去看醫生，被診斷為退化性關節炎(osteoarthritis)。在美國工作的親戚寄了”維骨力” (glucosamine)給她，她來醫院請教是否可吃，有沒有效? 會不會影響尿酸？

2. Patient’s concern 問題 Ask • 維骨力(glucosamine)對於退化性關節炎(osteoarthritis)有沒有疼痛緩解的效果? • 維骨力(glucosamine)會不會影響尿酸值?

3. 臨床問題(PICO-I) 問題 Ask

4. 臨床問題(PICO-II) 問題 Ask

5. 檢索 Aquire 搜尋策略 我們的「搜尋資源」包括：

6. 檢索 Aquire 搜尋策略,關鍵字

7. 檢索 Aquire 搜尋歷程Syntheses

8. 檢索 Aquire 搜尋結果 標題摘要內文

9. 檢索 Aquire 文章選定 • 符合臨床問題 • 研究設計適當 • 有全文 Level of evidence: 1 Systemic review of RCTs (Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence)

10. 檢索 Aquire 文章選定

11. 評讀 Appraise 嚴格評讀  Validity  Importance  Practice • Critical Appraisal Skills Program (CASP)

12. 評讀 Appraise 文獻評讀 • CASP- Systematic review  Yes To assess the effectiveness and toxicity of glucosamine in the pharmacological management of OA. Both symptomatic effectiveness and structural effectiveness (that is, delay in radiological progression of OA) were evaluated.

13. 評讀 Appraise Validity 嚴格評讀 • CASP- Systematic review  Yes The first criteria were used to screen all citations that involved glucosamine in the management of OA. The second criteria were used to identify those studies that met the following additional requirements: 1) RCTs evaluating the efficacy and toxicity of glucosamine in OA, 2) both placebo-based and comparative studies were eligible, 3) both single-blinded and double-blinded trials were eligible, 4) studies to be included in the quantitative portion of the review (meta-analysis) must have presented suitable quantitative data for pooling across trials, 5) studies that enrolled participants with OA at any body site were eligible with the only exception being studies that evaluated glucosamine in temporomandibular joint (TMJ) disorders, 6) only studies which evaluated glucosamine-only preparations were included (studies which evaluated combination products containing glucosamine in association with other active compounds, for example chondroitin, were excluded), 7) glucosamine could have been administered by any route.

14. 評讀 Appraise Validity 嚴格評讀 • CASP- Systematic review  Yes A MEDLINE search (1966 to November 1999) was used to identify all relevant RCTs for the first version of this Cochrane Review. For the second version of the Cochrane Review, all searches were updated (in January 2005). The same MEDLINE search strategy was extended for this updated version of the review (up to week 1, January 2008). MEDLINE In-Process and other non-indexed citations were also searched (January 2008); MEDLINE Daily Update was searched (January 2008). In addition, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library), AmericanCollege of Physicians (ACP) JournalClub, andDatabase of Abstracts of Reviews of Effectiveness (DARE) were searched (up to January 2008); Allied and Complementary Medicine (AMED) was searched (1985 to January 2008); and EMBASE was searched (1980 to week 2, January 2008

15. 評讀 Appraise Validity 嚴格評讀 • CASP- Systematic review  Yes Two review authors (TT and TP or LM) used the screening criteria to review all identified citations independently. All citations identified by either investigator were retrieved and analyzed for suitability. Authors of abstracts were contacted requesting the full manuscript, including the raw and final data incorporating the results.

16. 評讀 Appraise Importance 嚴格評讀 • CASP- Systematic review  Yes

17. 評讀 Appraise Importance 嚴格評讀 • CASP- Systematic review  Yes

18. 評讀 Appraise Importance 嚴格評讀 • CASP- Systematic review  Yes

19. 評讀 Appraise Practice 嚴格評讀 NNT;number needed to treat • 試驗終點是否為重要的臨床預後?  Yes

20. 應用 Apply 臨床應用 10 × 10 100位病人使用葡萄糖胺有17位病人的疼痛指標Lequesne Index獲得改善(NNT=6)

21. 應用 Apply 臨床應用

22. Evidence Systemic review of RCTs 35 35