EBM or cases or both? - Tom Jefferson

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EBM or cases or both? - Tom Jefferson

  1. 1. EBM or cases or both? Tom Jefferson Cochrane Ari Group , Cochrane Vaccines Field etc Jefferson.tomail.com Thanks to Dr Massimo Arlotti, Sebastiano Leone, Fabio Franzetti, Evangelo Boumis, Angelo Pan Celebrating case reports and stories in health care
  2. 2. EBM <ul><li>Mainly based on comparative studies (esp. their synthesis) </li></ul><ul><li>Randomised Controlled Trial/tightly controlled experimental paradigm </li></ul><ul><li>Non-randomised (comparative) studies </li></ul>Celebrating case reports and stories in health care
  3. 3. Problems <ul><li>Inductive methods </li></ul><ul><li>Uniformity of nature </li></ul><ul><li>Abstraction and generalisation </li></ul><ul><li>Patients in front of you not quite the same as those in trials </li></ul>Celebrating case reports and stories in health care
  4. 4. Celebrating case reports and stories in health care Repeated observation across different contexts Induction Theories and general principles Deduction Conclusions and explanations The arch of knowledge
  5. 5. When do we need case knowledge? <ul><li>Heavy contextualisation </li></ul><ul><li>Rare diseases </li></ul><ul><li>Harm monitoring </li></ul><ul><li>When controls are not available or not ethical </li></ul><ul><li>When other evidence is tainted </li></ul>Celebrating case reports and stories in health care
  6. 6. Guidelines for treating Serious Gram-Positive infections (Italian GISIG project) <ul><li>Systematic reviews of cases of: </li></ul><ul><li>Endocarditis </li></ul><ul><li>Brain abscesses </li></ul><ul><li>Joint / prostheses infections </li></ul>Celebrating case reports and stories in health care
  7. 7. Infective endocarditis (Dr Boumis) Celebrating case reports and stories in health care Reporting variable No missing / 19 reports Age 1 Comorbidities/risk factors 1 Symptom duration 3 Symptom descr 4 Physical examination findings 7 Imaging data 3 Lab data 13 Which valve involved 1 Agente sensitivity (MIC) 2 Antibiotic dosage 11 Antibiotic tx duration 6 Outcome description 4 Follow up duration 5
  8. 8. Standardisation <ul><li>Demographic/contextual variables </li></ul><ul><li>Prognostic profile </li></ul><ul><li>Diagnostic variables </li></ul><ul><li>Treatement </li></ul><ul><li>Harms </li></ul><ul><li>Outcome </li></ul><ul><li>Sufficient information to allow follow through by singles or groups of all these variables </li></ul>Celebrating case reports and stories in health care
  9. 9. Tom Jefferson B eware of red herrings How to read and listen to scientific items - Bufala spotting Case report quick assessment NO Is the topic of interest? YES Is presentation clear? YES NO Is the narrative logical? NO YES Is there a a declaration of conflicts? NO YES Is the sponsor identifiable? NO YES Can you reproduce the pathway? YES NO Are off-lables used Are there ethical Problems? No Yes
  10. 10. Warning <ul><li>Standardisation required (“tell the story”) </li></ul><ul><li>Coordination desperately needed </li></ul><ul><li>Web 2.0 to Web 3.0 </li></ul><ul><li>Huge numbers </li></ul><ul><li>Always interpret case evidence in the context of the current body of evidence </li></ul>Celebrating case reports and stories in health care

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