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 boxsummary box with up to five short single sentences highlighting new or particularly interesting things

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Contents EBCR course

Clinical case clinical scenario / case

Question clinical question (PICO)

Methods -search strategy/selection (fig1: flow chart)

-critical appraisal sorting (Table)

Results evaluation selected articles (Table?)

Discussion strong and weak points articles

Conclusion 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 questionWhat is it?

Critical question related to an acute + realistic problem concerning patient management for which a knowledge gap existsSpecific, answerable

What is the aim?Obtain clarity & certainty about the best patient management

Search; methods

Methods searchsee course book and practical lecture

Make it transparant!Table 1 with search strategy

Search; resultsTable 1: search strategy

Source files searched (internet)Combination of search terms (OR, AND)Numbers

Table 1: Search strategy

Database Search strategy hits Selected articles

Pubmed ((“magnetic resonance imaging” [MeSH]) AND (mammography) AND (“breast neoplasms” [MeSH])) AND (specificity[Title/ Abstract]) Limits

57 6

Embase (breast cancer) AND (MR) AND (premenopausal)

2 1

Cochrane Breast neoplasms AND Magnetic Resonance Imaging

19 0

Select; methodsReduction 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 criteriaNumbers not selected (per exclusion criterium)

Number articles, selected for further assessment (critical appraisal).

PubMed

Cerebrospinal fluid

Embase

Screening title abstract*

Filtering doubles

79 51

18 13

Exclusion criteria:-Animals

-Neonates-Adults

-Therapeutic study-CSF composition

not specified

Children with pneumococcal

meningitisMortality

AND

AND

Screening title abstract*

Full text availability

Useful:10 articles

18

Excluded because of:-Insufficient outcome

(mortality)-Experimental, non-

comparable CSF measurement

-Therapeutic study

Reading full text*

Inclusion criteria:-Prognostic study

-Mortality as outcome-CSF composition as

prognostic factor

13

27

1 article found by screening references

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 : random? consecutive? Allocation : randomization? inception cohort? Maintenance : masking? similar treatment?

drop out? Measurement : blinded? objective?

Critical Appraisal; Results

In table Criteria relevance Criteria validity

Specific for patient’s caseOwn simply applied systemNever forget legends

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Diagnosis Prognosis Therapy

Prediction Presence/absence disease

Course of disease Result of treatment

Domain Patient suspected of disease

Patient with dx and probability endpoint

Patient with Dx and probability endpoint

Determinant

As in practice As in practice Manipulated

Outcome reference test or -criterium

Mortality, morbidity,QoL

Mortality, morbidity, QoL

Type of study

Cross sectional

Follow up (time until outcome)

Follow up (time until outcome)

Design study

Descriptive Descriptive Causal

Outcome measure

AR AR RR/RD

Each question has own design

Strength of evidence; results

Summarizing table‘Best available evidence’ Consideration quality (relevance and validity) and amount information/studies best available evidence

Results and precisionConsistency - discrepancy result

Discussion

Interpretation results best available evidenceFormulation recommendation patientExplicit motivation recommendationConsiderations concerning relevance (restrictions?) validity (restrictions?)

EBCR- SummaryCaseClinical question

Text Introduction, clinical

question Justification: management

problemSearch strategy Flow chart Sources, selection,

numbersResults & selection criteria

Tables Relevance & validity Strength of evidence

Discussion Text Interpretation of the results Recommendations for

management Comments

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 practiceFill the knowledge gap

DisadvantagesDetailed / minute-to-minute management might be lackingBackground knowledge might also be lacking

Questions ?