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循证毒理学:因果关系的综合框架。

Evidence-based toxicology: a comprehensive framework for causation.

作者信息

Guzelian Philip S, Victoroff Michael S, Halmes N Christine, James Robert C, Guzelian Christopher P

机构信息

University of Colorado Health Science Center, Box B-146, 4200 East 9th Avenue, BRB 723, Denver, CO 80262, USA.

出版信息

Hum Exp Toxicol. 2005 Apr;24(4):161-201. doi: 10.1191/0960327105ht517oa.


DOI:10.1191/0960327105ht517oa
PMID:15957536
Abstract

This paper identifies deficiencies in some current practices of causation and risk evaluation by toxicologists and formulates an evidence-based solution. The practice of toxicology focuses on adverse health events caused by physical or chemical agents. Some relations between agents and events are identified risks, meaning unwanted events known to occur at some frequency. However, other relations that are only possibilities--not known to occur (and may never be realized)--also are sometimes called risks and are even expressed quantitatively. The seemingly slight differences in connotation among various uses of the word 'risk' conceal deeply philosophic differences in the epistemology of harm. We label as 'nomological possibilities' (not as risks) all predictions of harm that are known not to be physically or logically impossible. Some of these nomological possibilities are known to be causal. We term them 'epistemic'. Epistemic possibilities are risks. The remaining nomological possibilities are called 'uncertainties'. Distinguishing risks (epistemic relationships) from among all nomological possibilities requires knowledge of causation. Causality becomes knowable when scientific experiments demonstrate, in a strong, consistent (repeatable), specific, dose-dependent, coherent, temporal and predictive manner that a change in a stimulus determines an asymmetric, directional change in the effect. Many believe that a similar set of characteristics, popularly called the 'Hill Criteria', make it possible, if knowledge is robust, to infer causation from only observational (nonexperimental) studies, where allocation of test subjects or items is not under the control of the investigator. Until the 1980s, medical decisions about diagnosis, prevention, treatment or harm were often made authoritatively. Rather than employing a rigorous evaluation of causal relationships and applying these criteria to the published knowledge, the field of medicine was dominated by authority-based opinions, expressed by experts (or consensus groups of experts) relying on their education, training, experience, wisdom, prestige, intuition, skill and improvisation. In response, evidence-based medicine (EBM) was developed, to make a conscientious, explicit and judicious use of current best evidence in deciding about the care of individual patients. Now globally embraced, EBM employs a structured, 'transparent' protocol for carrying out a deliberate, objective, unbiased and systematic review of the evidence about a formally framed question. Not only in medicine, but now in dentistry, engineering and other fields that have adapted the methods of EBM, it is the quality of the evidence and the rigor of the analysis through evidence-based logic (EBL), rather than the professional standing of the reviewer, that leads to evidence-based conclusions about what is known. Recent studies have disclosed that toxicologists (individually or in expert groups), not unlike their medical counterparts prior to EBM, show distressing variations in their biases with regard to data selection, data interpretation and data evaluation when performing reviews for causation analyses. Moreover, toxicologists often fail to acknowledge explicitly (particularly in regulatory and policy-making arenas) when shortcomings in the evidence necessitate reliance upon authority-based opinions, rather than evidence-based conclusions (Guzelian PS, Guzelian CP. Authority-based explanation. Science 2004; 303: 1468-69). Accordingly, for answering questions about general and specific causation, we have constructed a framework for evidence-based toxicology (EBT), derived from the accepted principles of EBM and expressed succinctly as three stages, comprising 12 total steps. These are: 1) collecting and evaluating the relevant data (Source, Exposure, Dose, Diagnosis); 2) collecting and evaluating the relevant knowledge (Frame the question, Assemble the relevant (delimited) literature, Assess and critique the literature); and 3) Joining data with knowledge to arrive at a conclusion (General causation--answer to the framed question, Dose-response, Timing, Alternative cause, Coherence). The second of these stages (which amounts to an analysis of general causation), is addressed by an EBM-styled approach (adapted for the infrequent availability of human experimental studies in environmental toxicology). This involves assembling literature (through documented algorithms for database queries), excluding irrelevancies by use of delimiters as filters, and ranking and rating the remaining articles for strength of study design and for quality of execution gauged by application of either a ready-made quality assessment instrument or a custom designed checklist or scale. The results of this systematic review (including a structured review of relevant animal and in vitro studies) are then themselves systematically used to determine which causation criteria are fulfilled. Toxicology is maturing from a derivative science largely devoted to routinized performance and interpretation of safety tests, to a discipline deeply enmeshed in the remarkable advances in biochemistry and molecular biology to better understanding the nature and mechanism of adverse effects caused by chemicals. It is time for toxicologists, like scientists in other fields, to formalize a method for differentiating settled toxicological knowledge of risk from mere nomological possibility, and for communicating their conclusions to other scientists and the public. It is time for EBT.

摘要

本文指出了毒理学家当前在因果关系和风险评估的一些做法中存在的缺陷,并制定了一个基于证据的解决方案。毒理学实践主要关注物理或化学因素引起的不良健康事件。因素与事件之间的某些关系被确定为风险,即已知会以一定频率发生的不良事件。然而,其他仅为可能性(未知是否会发生,甚至可能永远不会实现)的关系有时也被称为风险,甚至还进行了定量表述。“风险”一词在各种用法中看似细微的内涵差异,掩盖了危害认识论中深刻的哲学差异。我们将所有已知在物理或逻辑上并非不可能的危害预测标记为“法则可能性”(而非风险)。其中一些法则可能性已知具有因果关系。我们将它们称为“认知性的”。认知性可能性就是风险。其余的法则可能性则称为“不确定性”。要从所有法则可能性中区分出风险(认知性的关系),需要了解因果关系。当科学实验以强有力、一致(可重复)、特定、剂量依赖、连贯、时间性和预测性的方式证明,刺激的变化决定了效应的不对称、方向性变化时,因果关系就可知了。许多人认为,一组类似的特征,通常称为“希尔标准”,如果知识充分,就有可能仅从观察性(非实验性)研究中推断因果关系,在这类研究中,受试对象或项目的分配不在研究者的控制之下。直到20世纪80年代,关于诊断、预防、治疗或危害的医学决策往往是权威性的。医学领域并非严谨地评估因果关系并将这些标准应用于已发表的知识,而是由专家(或专家共识小组)基于他们的教育、培训、经验、智慧、威望、直觉、技能和即兴发挥表达的基于权威的观点主导。作为回应,循证医学(EBM)应运而生,旨在认真、明确且明智地运用当前最佳证据来决定个体患者的治疗。如今在全球范围内得到认可,循证医学采用一种结构化、“透明”的方案,对关于一个正式构建的问题的证据进行审慎、客观、无偏且系统的审查。不仅在医学领域,而且现在在牙科、工程学以及其他采用循证医学方法的领域,得出关于已知情况的循证结论的是证据的质量以及通过循证逻辑(EBL)进行分析的严谨性,而非审查者的专业地位。最近的研究表明,毒理学家(个体或专家小组)在进行因果关系分析的审查时,在数据选择、数据解释和数据评估方面的偏见与循证医学之前的医学同行一样令人担忧。此外,当证据存在缺陷需要依赖基于权威的观点而非循证结论时,毒理学家往往未能明确承认(尤其是在监管和政策制定领域)(古泽利安PS,古泽利安CP。基于权威的解释。《科学》2004;303:1468 - 69)。因此,为了回答关于一般因果关系和特定因果关系的问题,我们构建了一个基于证据的毒理学(EBT)框架,该框架源自循证医学的公认原则,并简洁地表述为三个阶段,共包含12个步骤。这些步骤是:1)收集和评估相关数据(来源、暴露、剂量、诊断);2)收集和评估相关知识(构建问题、收集相关(限定范围)文献、评估和批判文献);3)将数据与知识结合以得出结论(一般因果关系——对构建问题的回答、剂量 - 反应、时间、替代原因、连贯性)。这些阶段中的第二个阶段(相当于对一般因果关系的分析),采用一种循证医学风格的方法(针对环境毒理学中人体实验研究很少可得的情况进行了调整)。这涉及收集文献(通过记录的数据库查询算法),使用限定词作为过滤器排除无关内容,并根据研究设计的强度以及通过应用现成的质量评估工具或定制设计的清单或量表衡量的执行质量,对其余文章进行排名和评级。然后,这个系统评价的结果(包括对相关动物和体外研究的结构化评价)本身被系统地用于确定哪些因果标准得到了满足。毒理学正在从一门主要致力于常规进行和解释安全测试的衍生科学,发展成为一门深深融入生物化学和分子生物学显著进展以更好地理解化学物质引起的不良反应的性质和机制的学科。现在是毒理学家像其他领域的科学家一样,正式确定一种方法来区分已确定的毒理学风险知识与仅仅是法则可能性,并将他们的结论传达给其他科学家和公众的时候了。循证毒理学的时代已经到来。

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