evidence based medicine, by prof badr mesbah
DESCRIPTION
Evidence based medicine, by prof Badr Mesbah. Professor of pediatric, Suez canal university Lecture presented in Port said fourth neonatology conference, 24-25 October 2013, Port said, EgyptTRANSCRIPT
Introduction to
Evidence based medicine
(EBM)
Badr Mesbah
Pediatrics Department and Clinical Epidemiology Unit Faculty of Medicine, Suez Canal University
What is evidence-based medicine?
• …an approach to practicing medicine in which
the clinician is aware of the evidence in support
of clinical practice, and the strength of that
evidence.
What is evidence-based medicine?
• Combines your clinical knowledge with your
knowledge of your patient, with evidence from
the literature
What is evidence-based medicine?
• Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values”
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2
Patient Concerns
Clinical Expertise
Best research evidence
EBM
Why EBM?
• Daily need for information
• Inadequacy of traditional sources of information
• Disparity between our diagnostic skills and clinical judgment vs. up-to-date knowledge and clinical performance
• Develop skills for lifelong learning
Steps to practice EBM
• Convert clinical questions into a searchable format.
• Search for evidence.
• Critically assess the information for validity and usefulness.
Steps to practice EBM
• Apply the information in clinical practice.
• Evaluate the performance of the information in clinical practice.
• Discover areas where more research is needed
The first step of EBM
• Convert a clinical situation into a searchable, (and hopefully answerable) question using
PICO•PATIENT
•INTERVENTION
•COMPARISON
•OUTCOME
PICO
PPatientatient
Intervention
Comparison
Outcome
“Patient” refers to the person presenting with the problem, or more simply, to the problem itself. Both concepts are important in searching.
PICO
Patient
IInterventionntervention
Comparison
Outcome
“Intervention” refers to the action taken in response to the problem. This is often a drug or surgical procedure, but it can take many forms
PICO
Patient
Intervention
CComparisonomparison
Outcome
“Comparison” refers to the benchmark against which the intervention is measured. Often it refers to another treatment, no treatment, or a placebo
PICO
Patient
Intervention
Comparison
OOutcomeutcome“Outcome” refers to the anticipated result of the intervention.
Search for evidence
• Types of Information Databases• Primary sources
– MedLine– Require more work to validate
• Secondary sources– Cochrane, Best Evidence, InfoPoems– Already reviewed - less work to validate– Limited amount of information studied
How good is the evidence?
- Is it from a peer-reviewed journal?
- Is the location and patients similar to mine?
- Sponsored by an organization that may influence
the study design or results?
- Will the information, if true, have an impact on
my patients and practice?
Study pyramid
Best
Worst
Levels of Evidences
• (I-1): a well done systematic review of 2 or more RCTs • (I-2): a RCT • (II-1): a cohort study• (II-2): a case-control study• (II-3): a dramatic uncontrolled experiment• (III): respected authorities, expert committees, etc.. • (IV): ...someone once told me....
Yalla, let’s try
Clinical Scenario
A family came with their 3 days old baby: We want to perform circumcision to our baby as his pain perception is minimal at this age. You know that this is not true and wondered about the best method of pain relief in this situation
Question (PICO)
Patients:
Intervention:
Comparison:
Outcome:
Newborn undergoing circumcision
Pharmacological and/or nonpharmacologicalinterventions
No intervention
Pain relief
Question
• In newborn infants undergoing circumcision (population), which pharmacological and/or non-
pharmacological interventions (intervention) provide the best pain relief (outcome)?
Search for evidence
Intervention Type of evidence Results Comments
Paracetamol versus placebo
Systematic reviews Paracetamol is effective in reducing postoperative pain
Benefit was noted only 6 hours after surgery
Dorsal penile nerve block versus no intervention
Systematic review Dorsal penile nerve block is effective in reducing painresponse
Bruising and/or hematoma canoccur at the site of injection
Search for evidence
Intervention Type of evidence Results Comments
Ring block versus no intervention
Systematic reviews Ring block is effective inreducing pain response
Further studies of ring block arerequired to demonstrate anysuperiority in efficacy andsafety compared to dorsal penile nerve block
EMLA versus nointervention
Systematic review EMLA decreases pain response
EMLA cannot be recommendedover local regional nerve block
Search for evidence
Intervention Type of evidence Results Comments
Sucrose with or without pacifier compared to waterwith or without pacifier
Systematic reviews Oral sucrose with or without pacifier is effective in reducing the pain response
Sucrose is not as effective asdorsal penile nerve block
Swaddling versus nointervention
Systematic review Swaddling reduces behavioralresponse
Current best practice for reducing pain associated with circumcision
• Administer 10–15 mg kg of acetaminophen within 2 hours before the procedure and every 4–6 hours
for 24 hours after the procedure.
• Offer a sucrose-dipped pacifier to the newborn before the dorsal penile nerve block, during the circumcision procedure, and after
Current best practice for reducing pain associated with circumcision
• Administer dorsal penile nerve block using lidocaine
• Swaddle the infant’s upper body during the circumcision
Future research needs • Further research is required to find ways to
reduce the exposure of newborns to painful stimuli and to refine the pain management for unavoidable, painful, medically indicated procedures..
Do developing countries really need EBM?
Definitely yes, more so than in Western world• Limited resources even more precious• Waste even more unacceptable when needs are great and budgets small• Often there is evidence that current practices
don’t work and should be abandoned• Best evidence doesn’t mean perfect evidence,
rather best available; solutions need to be appropriate for setting and resources
Summary• Evidence-based medicine is a systematic
approach to use up to date information in the practice of medicine
• Skills are needed to integrate the available evidence with clinical experience and patient concerns
• Application and evaluation of EBM skills will provide a framework for life-long learning.
Badr Mesbah
Thank you