Why evidence-based

case report?
Evidence Based
During the course of a day in the office, many questions will arise
that will require decisions

Case Report Ways to seek answers:

Asks expert colleagues

To go to the literature for good quality studies

This process of questioning and seeking answers will continue

throughout our professional career

The purpose of the Evidence-based Case Report (EBCR) is to

allow you to test this strategy for a question you would like to
explore further

Evidence-based case Evidence based case

reports report
Show how evidence can be applied at all stages of patient
A brief methods section explaining where you found the
care.
information.
Define the clinical question in four parts: Patient,
Max 1200 words (provide word count!)
Intervention, Comparison, Outcome (PICO)
Max 24 references
Show that you have searched for, cited, and summarized
studies of appropriate relevance, design, and quality, and
Max 4 illustrations (clinical photographs, imaging, line
should state which bibliographic databases you have
drawings, figures, tables)
used.
A summary box with up to five short single sentences
Answer the clinical question or state that there is no
highlighting new or particularly interesting things
answer available.
 EBCR Format Case description
3-5 typewritten pages in length and take the following format: Shorter than the
‘conventional’ case report
Case description (concise, highlights clinical problem in
question) Do not describe clinical
course in details
The question (PICOs)
Findings and particularities
Methods: The search & methods of appraisals
Motivation problem
Results: The answer/description of evidence
Knowledge gap (education,
Discussion/Conclusion: strong & weak points of the article study book, practice)

Apply the evidence Why important?

The Clinical Sample of question

Question(s)
Translation ‘clinical Should a 35 year old health care worker with a
bottom-line’, follows needle stick injury take AZT? (What is the
from description of evidence that a 35 yo health care worker who
problem.
takes AZT will reduce the risk of HIV
infection?)
Patient
Patient: health workers getting needlestick
Intervention injury

Comparison Intervention: AZT

Outcome Outcome: reduction of the risk of HIV

Methods The Search
Search strategy

Electronic searching

Database
The Search
Keywords & combination of search term(s):
AND, OR, brackets
Appraisals
Hand searching

Type of articles: inclusion & exclusion criteria

Make it transparent!

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Oxford Centre for Evidence based

Medicine Levels of Evidence (http://
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level of evidence -
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 Can I trust the accuracy of
data from a diagnostic study? Results
Recruitment: Was an appropriate spectrum of patients
included?

Spectrum bias The search/selection flowchart

Maintenance: All patients subjected to a Gold Standard? The evidence

Verification Bias
Appraisals & strength of evidence
Measurements: Was there an independent, blind or objective Description
comparison with a Gold Standard?

Observer Bias; Differential Reference Bias

Search Results
Selected
Database Search strategy Hits
articles

((magnetic resonance imaging[MeSH])

AND (mammography) AND (breast
Pubmed neoplasm[MeSH])) AND 57 6
(specificity[Title/ Abstract])

(breast cancer) AND (MR) AND

EMBASE (premenopausal) 6 1

Breast neoplasms AND Magnetic

Cochrane Resonance Imaging 2 0
Selection
Flowchart
 The evidence Appraisal & Strength
of Evidence
Narrative or table
Briefly describe the evidence and its strength Patient Rando-
Blinding
Criteria relevance selection mize

Look through the structure of the paper and

Criteria validity Study 1 + - -
think about each element of the study
Study 2 + + +
Specific for patient’s case
Was the study design a strong one? Study 3 - + +
Own simply applied system
Were the outcomes clinically significant?
Never forget legends
ARTICLE IN PRESS

doi:10.1510/icvts.2008.180083

Interactive CardioVascular and Thoracic Surgery 7 (2008) 698–701

Clinical review
www.icvts.org

Best evidence topic - Congenital

Is early primary repair ARTICLE
for correctionIN PRESS of tetralogy of Fallot

Summarizing evidence Table 1

comparable to surgery after 6 months of age?
H.A. Vohra et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) 698–701

Hunaid A. Vohra, Louise Adamson, Marcus P. Haw*

699

Best evidence papers Department of Cardiothoracic Surgery, Southampton General Hospital, Southampton, UK

Received 18 March 2008; received in revised form 10 April 2008; accepted 23 April 2008
Author Patient group Outcome Key results Comments

Ooi et al., (2006), 52 operations on children under Duration of post- Patients under 3 months Authors concluded that early
Evidence based case report Summary
Eur J Cardiothorac 12 months of age undergoing operative ventilation old required greater duration definitive repair of TOF can
Surg, UK w2x evidence topiccorrection
A best in cardiacofsurgery
isolated was
TOF written according to a structured(3.8"1.2 vs. 1.4"0.2
protocol. days; addressed
The question be performed
was whethersafelyearly
in those

Twenty year cough in a non-smoker P-0.05) under

primary repair for correction of tetralogy of Fallot (TOF) resulted in better outcomes than surgery after 6 months of age. 6 months old, 650
Altogether and that
Clinical review Cohort study (level
relevant 2b)were identified using the below mentioned search, eight papers represented the best evidence age
papers
Durationpatient
of ITU stay Those under
at surgery
to answer thedoes not
specific
Paul Glasziou question. The author, journal, date and country of publication, group studied, study3 type,
monthsrelevant
old appearresults
outcomes, to affect
andthe medium
study
weaknesses were tabulated. We conclude that early primary repair of TOF has been had longer
shown ITU stay
to be termrepair,
(11"4.1 to later
comparable haemodynamic
with several
vs. 5.1"0.8 days; P-0.05) outcome. They suggest that
retrospective series concluding that there is no increase in mortality with children under 6 months of age. Freedom from reintervention
repair in asymptomatic
has also been shown to be similar irrespective of the age primary repair is undertaken. However, it has been observed that length of
Duration of hospital Hospital stay was longer in patients can be delayed until
Editorial by Godlee Mrs V was
Studies a 66byyear
found old woman
a Medline searchwhoonsaid she had
causes components—firstly, chronic cough or synonyms, and
had cough
of chronic intensive care unit stay, period of mechanical ventilation and the need for inotropes is increased in patients undergoing primary repair at
stay patients under 3 months old 3–6 months of age
University of a non-productive cough almost daily for 20 years. This secondly, a “methodological filter”—to confine it to -3 months of age.
3 (24.8"8.9 vs. 14.9"1.3 days)
Irwin4 Mello5 Pratter6
Queensland had been treated unsuccessfully in the past Poe with anti- appropriate studies of differential diagnosis. A Medline ! 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Medical School, Setting but she was not taking any Community Referral Consecutive, Kolcz and Pizarro, (2005), Two groups of 66 consecutive Nakata index A significant increase in Nakata Authors conclude that
Queensland 4006, biotics, medication search using “chronic near cough” (the referral
special term Consecutive, referral Eur JKeywords:
Cardiothorac patients
Tetralogy of Fallot; with
Cardiac TOF and
surgery; Infants; Evidence based medicine index was observed only among neonatal repair affords a
Australia Yardstick Mrs V had good exercise tolerance,
currently. Retrospective review,
although nearChest x ray,that
means other*,
theplus
“chronic”Questionnaire,
and “cough” chest x ray,to be Questionnaire, respiratory
need Surg, USA w3x confluent pulmonary arteries neonates (98.54"44.6 vs. freedom from reintervention
including a non-to closeresponse
response to treatment
Paul Glasziou, she had an occasional wheeze at night. She was together but allows forother*,
termsplussuch as “chronic function tests, other*, plus
response to undergoing repair immediately 159.60"55.3; P-0.001) no different from patients
reader in clinical treatment treatment response to treatment
epidemiology
smoker and had never lived with smokers. Her chest non-productive cough”) yielded 343 references in just Cohort study (level 2b) after diagnosis repaired during infancy
Eligible/followed
was normal on upexamination. Her peak expiratory 134/139 flow 49/? 88/98 45/61 1. Introduction Freedom from 4. Search At 1strategy
month, 1 and 5 years was
P.Glasziou@spmed.
the past five years. This was too many, so the search Group I (ns46) had a median reintervention 100%, 84.2% and 81% in group
Asthma
rate was(%)500 (with a predicted value of 380),21and her needed to be24confined to articles that 14 were potentially 29
uq.edu.au A best evidence topic age ofwas constructed according to a
5 days Medline 1950
I and 100%, to84%
March 2008 using the OVID interface.
and 78.9%
spirometry result was good and showed 19
Postnasal drip (%) minimal most relevant. 41 I felt that a reasonable 38 methodological 56 structured protocol. This protocol is fully described in the wexp ‘Tetralogy
in group IIof Fallot’yor fallot.tix AND wexp infantyOR
(Ps0.88)
BMJ 1998;316:1660–1 (Acid
< 5%) response
reflux (%) to ! agonist. Nevertheless, because
4 filter might be21 to try to restrict references 40 to those with 11 ICVTS w1x. Group II (ns20) had a median neonat$.mp OR exp Infant, Newborny x and wrepair.mp or
asthma is an (%)
intermittent but common cause of9 cough, age of 56 days By multivariate
x. analysis,
Post infectious an appropriate — sample—that is, a random — or consecu- — correction.mp
preoperative weight (2.71"0.38
and
Chronicbecause
bronchitis,Mrs V had (%)
bronciectasis complained of nocturnal 4 tive set of cases,
5 plus an adequate yardstick 4 test or tests, — 2. Clinical scenario
vs. 3.62"1.04 kg; Ps0.02) and
wheeze, I decided to try her on a ! agonist aerosol (an 5. Search
lowoutcome
Other (%) — and an appropriate
— follow up (to catch8missed or mis- 4 A 6-week-old male infant is referred to your clinic by the arterial saturation in the
alternative would have been an inhaled steroid, but the taken diagnoses). Putting this together, I tried the early post op period
Undiagnosed (%) 14 2 paediatric cardiologists. He first presented with cyanosis A total(86.20"4.8
of 650 relevant papers were found from which
vs. 94.46"8.2;
response to treatment would have taken longer). following search: “chronic near cough,” “investigat* or and was found to have severe right ventricular outflow eight papers
*Other investigations were done Ps0.04) were selectedwith
were associated as representing the best
Meanwhile, I resolved to astrack
indicated
downby history, examination, and other test results.
the evidence tract obstruction (RVOT) with pulmonary stenosis and a evidence
diagnos* or cause*,” and “consecutive or follow up”. theonneed
thisfor
topic (Table 1).
reintervention
about other possible causes of Mrs V’s cough. This search produced the four studies described in large ventricular septal defect (VSD) on investigations. The during follow-up
the table,3–6 including the two that had been discussed cardiologist has just attended a national conference and 6. Comments
Sousa Uva et al., 56 patients with TOF operated Mortality One death after initial palliation Early primary repair of
Outcomefor evidence
Searching in Primary CareMrsMedicine.
V randomised to be
These studies hadonused
andsome-
off treatment for several heard about the practice of one stage repair of tetralogy
(1994), J Thorac on at -6 months of age (6.7%) andstudies
Eight clinical one death afterfound insymptomatic
were tetralogy
1720 patients. Theof
periods. This yardsticks,
would have of Fallot
Surg,(TOF) in neonates as an alternative to a palliative
what different diagnostic but, established
following the cause more Cardiovasc primary repair
studies reviewed the(2.4%) (Ps0.47)
operative outcomesFallot was achieved
in patients with a
under-
There
The first are
step many treatments
was to formulate for oesophageal
an answerable clinical reflux.
Irwin, 4
all clearly
required a . . . but
response a suitable
to specific placebo
treatment fora raising the head of
as
procedure
France w4x followed by a later repair. He asks
41 patients underwent primaryyou whether
going surgery for correction of TOF and
low mortality rate and is the
investigated wheth-
question —one of report
aetiology, differential you think this case repairmight be suitable for early Requirement
primary
in mydiagnosis,
1
for 56% of patients undergoing authors’ preferred protocol.
One published already files described a forthe
criterion diagnosis.
bed Given me.
escapes this need to establish repair.
Cohort study You
(leveldiscuss
2b) it with your consultant who askstransannular
you to er age at
patch
time of primary repair affected
primary repair required a
outcome.
They state that initial
diagnostic test accuracy, prognosis, treatment, or w2x, 52remains
randomised factorial trial of the individualresponse, and the follow up in most studies was quite review the literature.15 patients underwent initial In a retrospective study
transannular patch vs. by
13%Ooi et al.palliation operations
indicated
 Discussion EBCR - Summary
Case & Clinical Introduction, clinical question
Text
Question(s) Justification, management problems

Sources, selection, numbers

The Search Text
Appraisals
Flexibility in applying evidence
Results/the Flowchart, Relevance & validity
evidence tables, text Strength of evidence
The value of the clinical expert and the input
of the patient. Interpretation of results
Discussion/
Text Recommendation for management
conclusion
Comment

EBCR pro & cons

Advantages Disadvantages
Learn to apply Detailed / minute-to-
evidence-based minute management
practice might be lacking

Fill the knowledge Background

gap knowledge might also
be lacking
Question?