Evidence-Based Case Reports: Methods of design and reporting

Evidence-based case reports

Show how evidence can be applied at all stages of patient care.

Define the clinical question in four parts: Patient, Intervention, Comparison, Outcome (PICO) Show that you have searched for, cited, and summarised studies of appropriate relevance, design, and quality, and should state which bibliographic databases you have used.
Answer the clinical question or state that there is no answer available.
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Evidence-based case reports

A brief methods section explaining where you found the information. Max 1200 words (provide word count!). Max 24 references. Max 4 illustrations (clinical photographs, imaging, line drawings, figures, tables) A summary box with up to five short single sentences highlighting new or particularly interesting things
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Contents EBCR course

Clinical case Question Methods clinical scenario / case clinical question (PICO) -search strategy/selection (fig1: flow chart) -critical appraisal sorting (Table)

Results
Discussion Conclusion

evaluation selected articles (Table?)

strong and weak points articles answer question about patient!

Case
Detailed description
relevant characteristics findings & particularities

Motivation problem
knowledge gap (education, study book, practice) why important?

Research question
Translation clinical bottom-line, follows from description of problem.
Patient Intervention Comparison Outcome

EBM: clinical question

What is it? Critical question related to an acute + realistic problem concerning patient management for which a knowledge gap exists Specific, answerable
What is the aim? Obtain clarity & certainty about the best patient management

Search; methods
Methods search see course book and practical lecture
Make it transparant! Table 1 with search strategy

Search; results
Table 1: search strategy Source files searched (internet) Combination of search terms (OR, AND) Numbers
Table 1: Search strategy
Database Pubmed Search strategy ((magnetic resonance imaging [MeSH]) AND (mammography) AND (breast neoplasms [MeSH])) AND (specificity[Title/ Abstract]) Limits hits 57 Selected articles 6

Embase Cochrane

(breast cancer) AND (MR) AND (premenopausal) Breast neoplasms AND Magnetic Resonance Imaging

2 19

1 0

Select; methods
Reduction number titles Prior definition of exclusion and inclusion criteria

study type (design) domain, determinant, outcome

Screening title/abstract With doubt: screening full text

Select; results
Figure 1: flow chart selection (flow chart) Search results different databases (number) Clear exclusion criteria Numbers not selected (per exclusion criterium) Number articles, selected for further assessment (critical appraisal).

Children with pneumococcal meningitis

A N D PubMed

Cerebrosp inal fluid

A N D

Mortality

Embase 51

Exclusion criteria: -Animals -Neonates -Adults -Therapeutic study -CSF composition not specified Inclusion criteria: -Prognostic study -Mortality as outcome -CSF composition as prognostic factor Excluded because of: -Insufficient outcome (mortality) -Experimental, noncomparable CSF measurement -Therapeutic study

79 Screening title abstract* 18 Filtering doubles 27 Screening title abstract* 18 Full text availability 13 Reading full text*

13

1 article found by screening references Useful: 10 articles Not useful (domain: adults also included)

Search date: 30 November 2005 *All decisions were made by consensus or at least 2 authors

Critical Appraisal; Methods

Validity of the study (well performed?) Selection/selection bias Information bias Confounding Importance (were the results clinically importent?) Applicability/Relevance (applicable to my patient?)

Relevance for patient (patient included?) Patient, Intervention, Comparison, Outcome Search similarities & differences

Critical Appraisal; Methods

Validity of the study (well performed?) Selection bias? Confounding? Information bias?
RAMMbo Recruitment Allocation Maintenance Measurement

: random? consecutive? : randomization? inception cohort? : masking? similar treatment? drop out? : blinded? objective?

Critical Appraisal; Results

Similarity domain Similarity outcome

Specific for patients case Own simply applied system Never forget legends

Similarity determinant

In table Criteria relevance Criteria validity

Each question has own design

Prediction Domain Diagnosis Prognosis Presence/absenc Course of disease e disease Patient suspected Patient with dx and of disease probability endpoint Therapy Result of treatment Patient with Dx and probability endpoint

Determinant
Outcome Type of study

As in practice

As in practice

Manipulated
Mortality, morbidity, QoL Follow up (time until outcome) Causal RR/RD

reference test or - Mortality, morbidity, criterium QoL Cross sectional Follow up (time until outcome) Descriptive AR

Design study Outcome measure

Descriptive AR

Strength of evidence; results

Summarizing table
Best available evidence Consideration quality (relevance and validity) and amount information/studies best available evidence
Results and precision Consistency - discrepancy result

Discussion
Interpretation results best available evidence Formulation recommendation patient Explicit motivation recommendation Considerations concerning relevance (restrictions?) validity (restrictions?)

EBCR- Summary
Case Clinical question Search strategy

Text Introduction, clinical question Justification: management problem Flow chart Sources, selection, numbers
Tables Relevance & validity Strength of evidence Text Interpretation of the results Recommendations for management Comments

Results & selection criteria Discussion

Evidence based case reports Author requirements see www.bmj.com

Click at www.bmj.com under resources for authors, types of articles, practice, Evidence based case reports

Advantages
Learn to apply evidence-based practice Fill the knowledge gap

Disadvantages
Detailed / minute-to-minute management might be lacking Background knowledge might also be lacking

Questions ?