This document discusses evidence-based practice and summarizes a study on treating upper respiratory tract infections. It begins by defining key terms like magnitude and precision in appraising therapy effectiveness. It then asks what type of PICO question a given case study represents and the best study design to answer it. The case study is about treating a patient with nasal discharge, headache and sneezing. It suggests the PICO is a therapy question looking at antibiotics vs no antibiotics. The best design would be a randomized controlled trial. It then discusses critically appraising studies, looking at factors like randomization, blinding, follow up and equal treatment of groups. It summarizes a study on analgesics, reporting numbers needed to treat. It emphasizes appraising

1. Amna Khairy Abdul kareem
MBBS. MPH. MD community Medicine candidate

2.  Practical application of Appraisal terms
related to article on therapy:
Magnitude of therapy effectiveness
Precision of the results
 Application of critical appraisal scheme.

3. What is evidence-based practice?
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4.  Integration of
Best
available
research
evidence
Clinical
expertise
Patient’s
values
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6. 9/27/2018amna khairy abdul kareem 6
ask
acquire
appraiseapply
asses

7. a 23-year-old student, presenting with a 4-day
history of colored(pureulent)nasal discharge, headache,
lethargy and sneezing. She is taking
regular paracetamol for her headache. She is a non-
smoker with no significant medical history or drug
allergies and does not take any other regular
medicines. Her exams start in 2 weeks and she feels a
course of antibiotics will help her recover
.more quickly
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8. Population: Adults with URTI and purulent nasal discharge
Intervention: Antibiotics.
Comparison: No Antibiotics .
Outcome/s: Reduction of duration of illness.
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9.  What is the type of PICO?
 What is the best study design to answer this PICO
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PICO Question
Prevalence /
Etiology & risk factors
Diagnosis: signs,
symptoms or tests
Prognosis
Therapy
Study Design
Cross-sectional study
Cohort study/ Case–
control
RCT or cross sectional
Cohort study
RCT

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Relevance
• personal knowledge
Validity
Importance
• Results section
Applicability
• Personal Experience

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14. Abstract
 common problem
 outcome DOE(markers
of the disease) vs.
POEM(markers of
health).
 Change the practice
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Relevance

15. Therapy success(disappearance of symptoms that
most greatly affected the patient’s
health) at day 10 .
Duration of general illness, pain, and purulent nasal
discharge.
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17. Fair start Fair Race
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18.  1.Was the assignment of patients to treatment
randomized and randomization concealed?
 2. Were the groups similar at the start of the trial?
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19. Each participant should have an equal chance to
be in control or intervention group.
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21. Confounder is other factor that helped
improvement other than our intervention.
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23. combined HRT protect your heart!!
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26. “Healthy women effect”
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28. 3.Were the groups similar at the start of the trial? Ie
Proper Randomization
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30. Fair start Fair Race
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 1.Was follow-up of patients sufficiently long and
complete?
 2. Were all patients analyzed in the groups to
which they were
randomized?
3.Others

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33. Were all patients who entered the trial accounted for
at its conclusion?
And were they analyzed in the groups to which they
were randomized?
Was sensitivity analysis for outcome done?
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34.  Long enough for the outcome to develop.
 Complete . (no Attrition Bias)
Drop outs:
 If they were more than 30%, study should be
stopped.
 Intention to treat (once randomized always
analyzed).
 Sensitivity analysis.(worst case scenario).
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35. Were patients and clinicians kept "blind" to which
treatment was being received?
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Other points to insure fair race!

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5.Aside from the experimental treatment, were the
groups treated equally?

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All patients were allowed
to use symptomatic
treatment( decongestants
nose drops and
analgesics)

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Relevance
• personal knowledge
Validity
Importance
• Results section
Applicability
• Personal Experience

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Therapy
effectivene
ss
Precision
P value
Confidence
interval
Magnitude
ARR RRR
NNT/
NNH

42. Absolute Risk Reduction (ARR)
Relative Risk Reduction (RRR)
Number Needed to Treat (NNT)
Number Needed to Harm (NNH)

43. Control Death Rate
CER
12%
Experimental Death Rate
EER
9%
Absolute Risk Reduction (ARR) =3%
Relative isk Reduction (ARR)
=25%!!!!!!!!!!!!!!!!!!!
Numberr needed to treat(NNT)=33

44. Analgesic
Number of
patients in
comparison
Percent
with at
least
50% pain
relief
NNT
Lower
confidence
interval
Higher
confidence
interval
Ketorolac 60
(intramuscular)
116 56 1.8 1.5 2.3
Pethidine 100
(intramuscular)
364 54 2.9 2.3 3.9
Morphine 10
(intramuscular)
946 50 2.9 2.6 3.6
Ketorolac 30
(intramuscular)
359 53 3.4 2.5 4.9
Ketorolac 10
(intramuscular)
142 48 5.7 3.0 53.0

45. Control Event Rate
CER
0
Experimental Death
Rate
EER
1%
Absolute Risk Reduction (ARI) =1%
Number Needed to harm (NNH )= 100

46. We need to treat 33
Patients with MI to
prevent one death
We need to Give
thrombolytic to
100Patients with MI for
one to develop
intracranial he

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48.  95% Confidence interval :
 They are an estimate of the range of values that are
95 chance of including the real value.
Ep: NNT= 33 95% CI (20-40)

50. Study A Study B
ARR= 30%
95%CI( 10%-80%)
ARR = 20%
95% CI ( 15%- 22%)

51. Large sample size =
narrow CI
Small sample size =
Large CI

52. P-values: are a measure of the probability that a
result is purely due to chance. (0.05
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54. Can you do the
Intervention exactly as
it is described in the
paper?
Is your Patient similar to
the population of the
study?
Did you examine your
patient’s Preferences?
 Were all patient
important outcomes
considered?
 Are the potential
benefits outweigh the
potential harms & cost,
to my patient?
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55. Applicability
System
Preparedness:
Availability, Cost
etc
Staff Preparedness:
Knowledge, Skill
etc
Patient Factors &
Acceptability:
Similar to study
population,
Preferences, Values
etc
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Relevance
• personal knowledge
Validity
Importance
• Results section
Applicability
• Personal Experience

57. Questions and comments??
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58.  Email : amnakh22@gmail.com
 +249924659036
 Twitter : @amnakhairy
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