Slide “EBCR”
-
Upload
fatimah-hidayati -
Category
Documents
-
view
221 -
download
0
Transcript of 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