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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.
www.bmj.com
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
www.bmj.com
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
Sim
ilari
ty d
om
ain
Sim
ilari
ty
de
term
inan
t
Sim
ilari
ty o
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e
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 ?