Slide “EBCR”

8/6/2019 Slide EBCR

1/6

During the course of a day in the office, many questions will arisethat will require decisions

Ways to seek answers:

Asks expert colleagues

To go to the literature for good quality studies

This process of questioning and seeking answers will continuethroughout our professional career

The purpose of the Evidence-based Case Report (EBCR) is toallow you to test this strategy for a question you would like toexplore further

Show how evidence can be applied at all stages of patientcare.

Define the clinical question in four parts: Patient,Intervention, Comparison, Outcome (PICO)

Show that you have searched for, cited, and summarizedstudies of appropriate relevance, design, and quality, andshould state which bibliographic databases you haveused.

Answer the clinical question or state that there is noanswer available.

A brief methods section explaining where you found theinformation.

Max 1200 words (provide word count!)

Max 24 references

Max 4 illustrations (clinical photographs, imaging, linedrawings, figures, tables)

A summary box with up to five short single sentenceshighlighting new or particularly interesting things

8/6/2019 Slide EBCR

2/6

3-5 typewritten pages in length and take the following format:

Case description (concise, highlights clinical problem inquestion)

The question (PICOs)

Methods: The search & methods of appraisals

Results: The answer/description of evidence

Discussion/Conclusion: strong & weak points of the article

Apply the evidence

Shorter than theconventional case report

Do not describe clinical

course in details

Findings and particularities

Motivation problem

Knowledge gap (education,study book, practice)

Why important?

Translation clinicalbottom-line, followsfrom description of

problem.

Patient

Intervention

Comparison

Outcome

Should a 35 year old health care worker with aneedle stick injury take AZT? (What is theevidence that a 35 yo health care worker who

takes AZT will reduce the risk of HIV

infection?)

Patient: health workers getting needlestickinjury

Intervention: AZT

Outcome: reduction of the risk of HIV

8/6/2019 Slide EBCR

3/6

The Search

Appraisals

Search strategy

Electronic searching

Database

Keywords & combination of search term(s):AND, OR, brackets

Hand searching

Type of articles: inclusion & exclusion criteria

Make it transparent!

Validity, importance, applicability

Several standard tools are available

Rank the evidence

Useful scheme:

Oxford Centre for Evidence basedMedicine Levels of Evidence (http://www.cebm.net

)

!"#$%&'()%*+',-'.-/,-0'%1,/%-2%'345%1%$+67'89:'/,;%:%-)')%+?9-

!"#"$%&"'()*+(,-./(01-$2"34(56-2"4(7./'(7.)3-3*89(:-;$(0?@A89(B3.41(0?@A89(6"3"2*(E%F.GH(5>0?@A89(I$"44-/'3%(7.)"3-J9(,#-/(

A%4G1"K9(@%)(:1.$$.&49(-/'(E-="$(B1%3/L%/

' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' '

' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' '

!"#$%&' ()#*+,

-.#/#0+,12

()#*+3

-.#/#0+312

()#*+4

-.#/#0+412

()#*+5

-.#/#0+512

()#*+6+-.#/#0+62

L9B'29AA9-',+',)M+

-7898:+;@0@%#$2

A&$)+

8/6/2019 Slide EBCR

4/6

Recruitment: Was an appropriate spectrum of patientsincluded?

Spectrum bias

Maintenance: All patients subjected to a Gold Standard?

Verification Bias

Measurements: Was there an independent, blind or objectivecomparison with a Gold Standard?

Observer Bias; Differential Reference Bias

The search/selection flowchart

The evidence

Appraisals & strength of evidence

Description

Database Search strategy HitsSelectedarticles

Pubmed

((magnetic resonance imaging[MeSH])AND (mammography) AND (breast

neoplasm[MeSH])) AND(specificity[Title/ Abstract])

57 6

EMBASE(breast cancer) AND (MR) AND

(premenopausal) 6 1

CochraneBreast neoplasms AND Magnetic

Resonance Imaging 2 0

8/6/2019 Slide EBCR

5/6

Briefly describe the evidence and its strength

Look through the structure of the paper andthink about each element of the study

Was the study design a strong one?

Were the outcomes clinically significant?

Narrative or table

Criteria relevance

Criteria validity

Specific for patients case

Own simply applied system

Never forget legends

Patientselection

Rando-mize

Blinding

Study 1 + - -

Study 2 + + +

Study 3 - + +

Studies found by a Medline search on causes of chronic coughPoe3 Irwin4 Mello5 Pratter6

Setting Community Referral Consecutive, referral Consecutive, referral

Yardsti ck Retrospective revi ew,including response to

treatment

Chest x ray, other*, plusresponse to treatment

Questionnaire, chest x ray,other*, plus response to

treatment

Questionnaire, respiratoryfunction tests, other*, plus

response to treatment

Eligible/followed up 134/139 49/? 88/98 45/61

Asthma (%) 21 24 14 29

Postnasal drip (%) 19 41 38 56

Acid reflux (%) 4 21 40 11

Post infectious (%) 9

Chronic bronchitis, bronciectasis (%) 4 5 4

Other (%) 8 4

Undiagnosed (%) 14 2

*Other investigations were done as indicated by history, examination, and other test results.

Summarizing evidence

Evidence based case report

Twenty year cough in a non-smokerPaul Glasziou

i- i i i

i i i-i i , i i i

i ,i i -

i ii i i

i i ,i i i

i ,i i i ,

i, i ii i i ,

i , ii

i i ii 1 i , i i i i ,

i i , i , ,i i i i i i i

i , i ,

, i i i ii i i i i i i

i i ii

i- i i i

i i ,i i i

ii i i i

i i , -i , i ,

i i i -i i i , i

i i , i ii , i

i i i i, i i i

i i i i i -i i i i , , i

i , i i ii i i i i i i

, i i i

i r i

i ,,

r i

i ,

. i .. .

1 ; 1 : 1 1

Table 1

Best evidence papers

Author Patient group Outcome Key results Comments

Ooi et al., (2006), 5 2 oper a tions on chil dren under D ura t ion of post - Pat ient s under 3 mont hs Authors concluded t hat ea rl y

Eur J Cardiothorac 12 months of age undergoing operative ventilation old required greater duration definitive repair of TOF can

Surg, UK w2x correction of isolated TOF (3.8"1.2 vs. 1.4"0.2 days; be performed safely in those

P-0.05) under 6 months old, and that

Cohort study (level 2b) age at surgery does not

Duration of ITU stay Those under 3 months old appear to affect the medium

had longer ITU stay (11"4 .1 t erm ha emodynamic

vs. 5.1"0.8 days; P-0.05) outcome. They suggest that

repair in asymptomatic

Duration of hospital Hospital stay was longer in patients can be delayed until

s tay p ati en ts un der 3 m on ths ol d 36 months of age

(24.8"8.9 vs. 14.9"1.3 days)

Kolcz and Pizarro,(2005), Two groups of 66 consecutive Nakata index A significant increase in Nakata Authors conclude that

E ur J C ar di ot ho ra c p at ie nt s w it h T OF a nd i nd ex w as o bs er ve d o nl y a mo ng n eo na ta l r ep ai r a ff or ds a

Surg, USA w3x c on fl ue nt p ul mo na ry a rt er ie s n eo na te s(98.54"44.6 vs. freedom from reintervention

u nd er go in g r ep ai r i mm ed ia te ly 1 59 .6 0"55.3; P-0.001) no different from patients

Cohort study (level 2b) after diagnosis repaired during infancy

Freedom from At 1 month, 1 and 5 years was

Group I (ns46) had a median reintervention 100%, 84.2% and 81% in group

age of 5 days I and 100%, 84% and 78.9%

in group II (Ps0.88)

Group II (ns20) had a median

age of 56 days By multivariate analysis,

preoperative weight (2.71"0.38

vs. 3.62"1.04 kg; Ps0.02) and

low arterial saturation in the

early post op period

(86.20"4.8 vs. 94.46"8.2;

Ps0.04) were associated with

the need for reintervention

during follow-up

l i i r r li r i i i l lli i rl ri r r ir

r r i r l

r i r ri r r ir s ll i i

r i r ri r l r li r i

r ir ir r i r i r r rr r l

r l l r l r ri r r ir r ir i i i l

i r i i i l r l r lli i r i i i

.i cv . r

i: . icv . .

I r c iv C r i c l r T r cic r r 7 7

Best evidence topic - Congenital

Is early primary repair for correction of tetralogy of Fallotcomparable to surgery after 6 months of age?

L *

t t i t cic , t t l it l, t t ,

c iv rc ; r c iv i r vi f r ril ; cc ril

r

i i i r i r r ri r i r r r l i r r rlri r r ir r rr i r l ll r l i r r r r l r

r l r r i i i i l i r i r r r i r i ii r r l r l i i i r i r l r l

k r l l rl ri r r ir r l l r r ir i r lr r i r i l i r i i r i r li i il r r r r r i r i

l i il r irr i ri r r ir i r k r i r l

i i r i ri i l il i r i r i i r i i r i ri r r ir

li r i i r r i - r i r r ll ri r r

: T r l f F ll ; C r i c r r ; I f ; Evi c ici

I

- -

I

I

--

I

8/6/2019 Slide EBCR

6/6

Flexibility in applying evidence

The value of the clinical expert and the inputof the patient.

Case & ClinicalQuestion(s)

TextIntroduction, clinical question

Justification, management problems

The Search TextSources, selection, numbers

Appraisals

Results/theevidence

Flowchart,tables, text

Relevance & validityStrength of evidence

Discussion/conclusion

TextInterpretation of results

Recommendation for managementComment

Learn to applyevidence-basedpractice

Fill the knowledgegap

Detailed / minute-to-minute managementmight be lacking

Backgroundknowledge might alsobe lacking

Advantages Disadvantages