Evidence based medicine, by prof Badr Mesbah


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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, Egypt

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Evidence based medicine, by prof Badr Mesbah

  1. 1. Pediatrics Department and Clinical Epidemiology Unit Faculty of Medicine, Suez Canal University Introduction to Evidence based medicine (EBM) Badr Mesbah
  2. 2. 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.
  3. 3. What is evidence-based medicine? • Combines your clinical knowledge with your knowledge of your patient, with evidence from the literature
  4. 4. What is evidence-based medicine? • Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” Patient Concerns EBM Clinical Best research Expertise evidence 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
  5. 5. 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
  6. 6. Steps to practice EBM • Convert clinical questions into a searchable format. • Search for evidence. • Critically assess the information for validity and usefulness.
  7. 7. 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
  8. 8. The first step of EBM • Convert a clinical situation into a searchable, (and hopefully answerable) question using PICO • PATIENT • INTERVENTION • COMPARISON • OUTCOME
  9. 9. PICO Patient 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.
  10. 10. PICO Patient “Intervention” refers to the action taken in Intervention response to the problem. This is often Comparison a drug or surgical procedure, but it can Outcome take many forms
  11. 11. PICO Patient “Comparison” refers to Intervention the benchmark against Comparison which the intervention is measured. Often it refers to another Outcome treatment, no treatment, or a placebo
  12. 12. PICO Patient Intervention Comparison Outcome “Outcome” refers to the anticipated result of the intervention.
  13. 13. 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
  14. 14. 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?
  15. 15. Study pyramid Best Worst
  16. 16. 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....
  17. 17. Yalla, let’s try
  18. 18. 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
  19. 19. Question (PICO) Patients: Newborn undergoing circumcision Intervention: Pharmacological and/or nonpharmacological interventions Comparison: No intervention Outcome: Pain relief
  20. 20. Question • In newborn infants undergoing circumcision (population), which pharmacological and/or nonpharmacological interventions (intervention) provide the best pain relief (outcome)?
  21. 21. 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 pain response Bruising and/or hematoma can occur at the site of injection
  22. 22. Search for evidence Intervention Type of evidence Results Comments Ring block versus no intervention Systematic reviews Ring block is effective in reducing pain response EMLA versus no intervention Systematic review EMLA decreases pain response Further studies of ring block are required to demonstrate any superiority in efficacy and safety compared to dorsal penile nerve block EMLA cannot be recommended over local regional nerve block
  23. 23. Search for evidence Intervention Type of evidence Results Comments Sucrose with or without pacifier compared to water with or without pacifier Systematic reviews Oral sucrose with or without pacifier is effective in reducing the pain response Sucrose is not as effective as dorsal penile nerve block Swaddling versus no intervention Systematic review Swaddling reduces behavioral response
  24. 24. 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
  25. 25. 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
  26. 26. 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..
  27. 27. 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
  28. 28. 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.
  29. 29. Thank you Badr Mesbah