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Jingdong book

治疗的真相

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治疗的真相

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这是一本揭示医学治疗真相的科普读物,由循证医学的主要奠基人伊恩?查默斯等人所著,已被翻译成12种文字,在全世界广为传播。作者以公众容易知晓的知识、词汇和语言,以及深入浅出的方法,揭示医学治疗和研究的真相。原卫生部副部长王陇德院士推荐本书,认为它“价值连城”。

Content Description

这是一本有关医学治疗与健康的循证科普图书,世界**的医学期刊《柳叶刀》和《英国医学杂志》给予了高度评价,至今已被译成12种文字在全世界传播。它通过详实的数据、鲜活的例子和通俗易懂的语言来揭示医学诊断和治疗领域不为人知的真相,适合医务人员及任何对健康感兴趣的人阅读。

本书帮助读者拨开迷雾,学会甄别哪些医学信息值得信任,哪些是原以为有效和正确的诊疗方法,其实会对健康带来弊端;帮助读者认识医学研究在设计、实施和发表过程中可能存在的问题和偏倚;还鼓励读者,通过主动参与医学研究和临床试验,用科学的医学知识防治疾病,促进健康。

原卫生部副部长王陇德院士推荐本书,认为它“价值连城”——为迈向世界卫生组织提出的“人人享有健康”的目标提供了一条重要的途径,也是普通百姓*容易掌握的途径。

Author Description

资深医师、卫生服务研究者,创建牛津大学国家围产期流行病学研究所及循证医学中心,1993年创建国际循证医学协作网。2003年起,领导詹姆斯林德计划。

Comments

《治疗的真相》告诉不同的患者、医生与科学家同样的真相!

——《柳叶刀》

《治疗的真相》是当前介绍有关医学治疗方法、应用与价值的入门宝典。

——《健康事务》

不仅是医务人员,任何对健康感兴趣的人都应该去阅读它!

——《临床研究实践杂志》

我再怎么强烈推荐这本伟大的书都不为过,因为它条理清晰、哲理深邃且兼具人文情怀。

——本·?高达可,《小心坏科学》

我毫不犹豫地推荐这本书,并确信它百看不厌。

——乔治·加利亚,《英国皇家病理学院公报》

Catalogue

中文版序王陇德/ 1

译者前言杨克虎陈耀龙/ 4

作者简介/ 001

致谢/ 003

序/ 005

第一版序/ 011

前言/ 015

引言/ 018

第 1章“新的”就是“更好的”吗?/ 025

第 2章 预期的效果没有变为现实/ 041

第 3章 越多未必越好/ 051

第 4章 越早未必越好/ 063

第 5章 应对疗效的不确定性/ 085

第 6章 验证疗效的无偏倚试验/ 103

第 7章考虑偶然因素/ 127

第 8章评价所有相关的可靠证据/ 135

第 9章对无偏倚试验的监管:是推动还是阻碍?/ 151

第 10章高质量、低质量和不必要的研究/ 165

第 11章做好的研究,人人有责/ 185

第 12章如何把卫生保健做得更好?/ 201

第 13章合理的研究:未来更美好的蓝图/ 223

参考文献/ 235

额外资源/ 263


Book Abstract

第 1章“新的”就是“更好的”吗?

其他国家也面临强烈要求使用赫赛汀的压力。例如在新西兰,患者支持小组、新闻媒体、药商和政府官员都要求为早期乳腺癌患者使用赫赛汀。和英国国家卫生与临床优化研究所职能类似的新西兰药品管理局(Pharmaceutical Management Agency, PHARMAC)也审查了赫赛汀治疗早期乳腺癌患者的证据。2007年 6月,基于上述审查结果,新西兰药品管理局确定早期乳腺癌患者适合服用 9周的赫赛汀,在此期间需同时服用其他抗癌药物,还不能以先后顺序服用。这种 9周疗程法是当时全球都在使用的三种用药疗程之一。新西兰药品管理局还专门划拨资金资助一项关于赫赛汀治疗最佳疗程的国际合作研究。然而在2008年 11月,新选举出来的政府官员忽视了药品管理局的循证决策,宣布立项资助研究该药 12月疗程的效果。

关于赫赛汀的使用还存在很多的不确定性——例如,服用该药的时间、应服用多久、该药对某些患者的长期作用是否弊大于利、该药是否可以延迟或者防止癌症的复发。还出现了另外一个担忧:该药和诸如蒽环类药物、环磷酰胺的抗乳腺癌药物一起服用,可能会使患者产生心脏病副作用的概率从 4%增加至27%。

要点

验证新的治疗方案是必要的,因为有可能新疗法并不比现有的治疗方式更好

对治疗方案进行有偏倚的(不科学的)试验可导致患者遭受痛苦甚至死亡

事实上,被批准的治疗并不能保证就是安全的

治疗的副作用通常需要经过一定时间才会出现

治疗的好处常常会被夸大,而害处则会被淡化

第 2章 预期的效果没有变为现实

有些疗法在经过长期使用后,人们才会意识到它们弊大于利,可见,预期效果存在无法实现的可能性。在这一章中我们会解释为什么会这样。

对婴儿睡姿的建议

不要以为只有药物会产生伤害,医学专家的建议同样可以致命。许多人都听说过美国儿童保健专家本杰明?斯波克(Benjamin Spock)医生,他的畅销书《婴儿与儿童保健》

(Baby and Child Care)几十年来一直被父母和专家们奉为育儿宝典,在美国和英国尤其如此。但斯波克医生却因他给出的一条善意的建议而铸成大错。这条建议从逻辑上看似乎无可辩驳,而且颇具权威性。从 1956年著作的出版直到 20世纪 70年代末,他一直认为:“婴儿躺着睡有两大坏处:一是如果婴儿呕吐,躺着睡使他更可能被呕吐物呛噎;二是婴儿倾向于将头一直偏向同一边……这可能使一侧头部扁平……我认为最好一开始就让婴儿习惯趴着睡。”

婴儿睡姿建议是怎样随时间推移而改变的

让婴儿趴着睡不仅成了医院的标准规范,也被数百万父母在家中尽职尽责地执行着。但我们现在才发现,这种从未经过严格评价的做法导致了数以万计的婴儿猝死,而这些悲剧本可避免。 1当然,并非所有的婴儿猝死事件都归咎于这条令人遗憾的建议,但在摒弃了这一做法并提出让婴儿躺着睡的建议后,婴儿猝死事件的发生明显减少。当 20世纪 80年代关于趴着睡的有害证据清晰地出现时,医生和媒体开始警告该睡姿的危险,之后婴儿猝死事件的数量开始大幅度下降。随后这一事件演化成了一项名为“躺着睡(back to sleep)”的运动,尽可能消除斯波克医生那条令人痛惜的建议所产生的不良影响。

用于心脏病发作后患者抗心律异常的药物

斯波克医生的建议曾看上去符合逻辑,但它基于未经验证的理论。类似的例子还有很多。有些患者在心脏病发作后会出现心律异常——也就是心律失常。这些患者比起未出现心律失常的患者更容易死亡。由于有药物能够抑制心律失常,于是便假设这些药物也能降低心脏病发作后死亡的风险,这似乎符合逻辑。实际上这类药物恰好有相反的效果。这类药物确实进行了临床试验,但目的仅仅是为了验证它们是否能减少心律失常。1983年研究人员系统评价了试验所累积的证据,发现没有证据表明这些药物能降低病死率。

然而,这类药物在长达近 10年的时间里却继续被使用,继续导致患者死亡。20世纪 80年代后期是抗心律失常药物使用的高峰期。据估计,在这一时期,仅在美国该药每年导致数万人早死。每年由于该药致死的美国人数比越南战争期间阵亡的还要多。 3随后人们发现,某些提示该药物可致死的试验结果出于商业目的从未被报告(见第 8章,第 114页)。

己烯雌酚

曾经有段时间,医生不确定对有流产和死产史的孕妇服用己烯雌酚(DES)这种合成雌激素是否有益。有些医生将其作为处方药,有些医生则没有。20世纪 50年代初期,己烯雌酚开始盛行,被认为可以改善胎盘功能障碍,而这种障碍有可能是引起流产或死产的原因。报告称有流产和死产史的妇女经己烯雌酚治疗后产下活婴,这使得那些使用过己烯雌酚的医生备受鼓舞。

例如,一名英国产科医生给一位有过两次死产经历的女性患者从妊娠早期开始便开了己烯雌酚这种药物。这位孕妇最后产下一名活婴。这位产科医生推断该妇女成功分娩的“自然”能力在这段时间可能已经得到改善,因此在她第四次妊娠期间停用了己烯雌酚;但婴儿因“胎盘功能不全”在子宫内死亡。所以,在她第五次和第六次妊娠期间,这位产科医生和这位妇女都毫不犹豫地认为应再次使用己烯雌酚,结果这两次妊娠都产下了活婴。这位产科医生和妇女由此得出己烯雌酚是有用的药物。不幸的是,根据这一事件得出的结论从未经过严格的无偏倚试验验证。在该妇女接受这种治疗的同时,实际上无偏倚的研究正在进行,研究报告并没有发现己烯雌酚有益的证据。

无偏倚试验没有得出己烯雌酚有助于预防死产的证据,但有关己烯雌酚的话题并未就此终结。20年后,有害的副作用证据开始出现:有位母亲对患了罕见阴道癌的女儿的病因进行了仔细观察,发现女儿的患病很可能跟她自己在妊娠期间服用己烯雌酚有关。 这一观察十分重要,而更重要的是,它后来被验证是正确的。此后,大量研究显示无论男女,凡出生前接触过己烯雌酚,便会有各种各样的严重副作用。这些副作用不仅包括罕见癌症的发生率增加,还包括生殖系统的其他异常。

己烯雌酚被正式宣布不能用于妊娠期之时,已有数百万人用过此药。若当时我们了解现在所知事实的真相,如果在 20世纪 50年代医生们就利用当前最可靠的己烯雌酚研究证据,那么很少有医生会再给患者开这种药,因为从一开始被作为处方药使用时,己烯雌酚就从来没有被证明是有效的。可悲的是,疗效证据的缺乏被人们普遍忽视了。

激素替代疗法(HRT)

对于更年期妇女常见的烦人的热潮红,激素替代疗法

(hormone replacement therapy, HRT)疗效显著,且有证据表明这种疗法可能有助于预防骨质疏松。激素替代疗法的益处逐渐被越来越多地挖掘,例如它可以预防心脏病及卒中。数百万妇女在医生的建议下开始长期使用激素替代疗法。然而,这种做法的依据却非常不可靠。

……

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