Journal of Pediatric Urology (2019) 15, 409e411

Educational Article

Evidence Based Medicine IV: how to find

an evidence-based answer to a clinical
question? Make a critically appraised
a
Department of Urology,
topic!
Pediatric Urology Section,
Amsterdam University Medical
Centre Location VUmc, G.M.A. Beckers a,*, K. Herbst b, M. Kaefer c, L. Harper d,
Amsterdam, the Netherlands
M. Castagnetti e, D. Bagli f, N. Kalfa g, M. Fossum h, On behalf of the
b
Division of Urology, ESPU Research Committee
Department of Research,
Connecticut Children’s Medical
Center, Hartford, CT, United
States
Summary appraised topic). The way how to write a cat is
This manuscript is the fourth in a five part series described for interventions to be compared to a
c
Riley Hospital for Children, related to evidence based medicine (EBM) provided control group, and for other, more generalized
Indiana University, by the European society of pediatric urology (ESPU) clinical questions. While systematic reviews provide
Indianapolis, IN, United States
research committee. It will present a way to come a throughout overview of all evidence available, a
d
Service de Chirurgie to a quick and critical appraisal of available CAT provides a shorter way to come to quick
Pédiatrique, Hôpital Pellegrin- evidence on a specific topic: a CAT (critically insights based on EBM.
Enfants, CHU de Bordeaux,
France
e
Section of Pediatric Urology,
University Hospital of Padova, Physicians are often confronted with doubt in intervention, to the control group, and to the
Padua, Italy
how to deal with a particular clinical situa- outcome (Fig. 1).
f
Division of Urology, tion or what is known about a specific con- All rules of Evidence Based Medicine have
Department of Surgery and dition. It is often unpractical, if not to be respected. The next step, therefore, is
Physiology, University of
Toronto, Developmental and impossible, to comply with the requirements to search a chosen database, PubMedª, for
Stem Cell Biology, The Hospital of a systematic review. A critically appraised example, while adhering to the rules for good
for Sick Children and Research
Institute, Toronto, Ontario,
topic or CAT, a method of conducting an literature search (Fig. 2).
Canada abbreviated systematic review, can be a Narrowing of search criteria depends on
g good alternative. the specific question at hand. One can limit
Service de Chirurgie
Urologique Pédiatrique, Hôpital When conducting a CAT, one has to obey all the search to reviews only (Fig. 3), to case
Lapeyronie, CHU de rules of a systematic review [1]. The differ- reports, or to whatever category of manu-
Montpellier, Université de
Montpellier, France
ence is that with a CAT one can narrow the scripts that will best provide the answer
h
search to a specific period of time or a limited one is looking for. Appropriate study designs
Division of Pediatric Urology, number of journals. This simplifies the have to be described well [2], and for each
Astrid Lindgren Children’s
Hospital, Karolinska University search strategies, thereby smoothing the way manuscript selected, the study population,
Hospital, Department of to obtaining information. This does not mean the risk of bias, and the study outcome
Women’s and Children’s
Health, Karolinska Institutet,
that cherry picking of positive results is have to be described. Particular emphasis
Stockholm, Sweden allowed! must be placed on determining whether the
* Corresponding author. Department CATs can focus on interventions, but they study is reproducible and applicable to the
of Urology, pediatric urology section,
Amsterdam University Medical can also address a clinical question without patient group one is focused on.
Centre Location VUmc, de Boelelaan an intervention or for which a control group In cases where an intervention is not central
1117, 1081HV Amsterdam, the
Netherlands. Tel.: þ31204440261. is not available. to the question, the ‘I’ can stand for incidence,
gma.beckers@amsterda- When it is possible for an intervention to be risk factor, prevalence, and so on and the ‘C’
mumc.nl (G.M.A. Beckers) compared to a control group, a CAT takes the for cofactors or confounders influencing the
Keywords
form of a PICO. Here, the first step is a good risk vis-à-vis a certain outcome. Again, by
Evidence-based medicine; Crit- problem description including the description writing out items and searching for specific
ically appraised topic; Educa- of the research population. This is to be fol- terms (e.g. MeSH-terms), one can find avail-
tional article; Review; Level of lowed by a concise description of the inter- able literature and summarize in a systematic
evidence
vention and the control group and the way (Figs. 3 and 4).
outcome of both groups. Search terms can be CATs serve as the first step to quickly get
Received 4 May 2019
Accepted 8 May 2019
adapted to the population in question, to the an overview of available literature. This in
Available online 14 May 2019

https://doi.org/10.1016/j.jpurol.2019.05.009
1477-5131/ª 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
410 G.M.A. Beckers et al.

In children under 12 years of age, are topical steroids beer to treat lichen sclerosus (balanis
xleroca et obliterans) of the foreskin than a circumcision?

Date: Descripon Mesh term Other possible search

30-09-2018 terms
P Populaon Children under 12 years of age Child Boy
with Balanis Xleroca et Balanis Xleroca BXO
obliterans Obliterans
I Intervenon Topical steroids Steroids Topical steroids, steroid
applicaon
C Control Circumcision Circumcision, Male circumcision,
male medical male
circumcision,…
O Outcome Disappearance of BXO

Fig. 1 Example of the first step to work out a CAT (intervention to be compared to a control group).

What is the best treatment for lichen sclerosus(balanis scleroca et obliterans) of the foreskin in
children under 12 years of age?

Search strategy in Pubmed© Number of Number Number of

Date: 30-09-2018 manuscripts of reviews that
retrieved reviews might fit to the
research
queson
BXO[All Fields] AND ("child"[MeSH Terms] OR 29 2 1
"child"[All Fields])
BXO[All Fields] 63 5 3
("balanis xeroca obliterans"[MeSH Terms] OR 229 35 14
("balanis"[All Fields] AND "xeroca"[All Fields]
AND "obliterans"[All Fields]) OR "balanis xeroca
obliterans"[All Fields]) AND Review[ptyp]
("steroids"[MeSH Terms] OR "steroids"[All Fields]) 139 17 7
AND ("circumcision, male"[MeSH Terms] OR
("circumcision"[All Fields] AND "male"[All Fields])
OR "male circumcision"[All Fields] OR
"circumcision"[All Fields])

Fig. 2 Examples of literature search on a question NOT comparing interventions. The example is not complete!

What is the best treatment for lichen sclerosus (balanis xleroca et obliterans of the foreskin) in
adults?

Date: Descripon Mesh term Other possible search terms

30-09-2018
P Populaon Adults Adult Adults
I Treatment Treatment Therapy Treatment; Surgery;
Conservave;…
C Condion Balanis Xleroca et Balanis Xleroca BXO; lichen sclerocus;…
Obliterans Obliterans
O Outcome Cure of the condition

Fig. 3 Example of the first step to work out a CAT for a question NOT comparing interventions.

turn will help one decide on a clinical question or to output or that can guide you through your structured
determine if a systematic literature review is already in review are www.casp-uk.net or www.equator-network.
existence. Websites that can help you structure your org.
Evidence Based Medicine Part IV 411

In adults, are topical steroids beer to treat lichen sclerosus (balanis xleroca et obliterans) of the
foreskin than a circumcision?

Search strategy in Pubmed© Number of Number Number of

Date: 30-09-2018 manuscripts of reviews that
retrieved reviews might fit to the
research
queson
("adult"[MeSH Terms] OR "adult"[All Fields]) AND 28 2 1
BXO[All Fields]
BXO[All Fields] 63 5 2
("adult"[MeSH Terms] OR "adult"[All Fields]) AND 20 2 1
BXO[All Fields] AND ("therapy"[Subheading] OR
"therapy"[All Fields] OR "therapeucs"[MeSH
Terms] OR "therapeucs"[All Fields])
("adult"[MeSH Terms] OR "adult"[All Fields]) AND 0 0 0
BXO[All Fields] AND cure[All Fields]

Fig. 4 Examples of literature search on question an intervention to be compared to a control group. The example is not
complete!

Author statements References

Ethical approval [1] Callander J, Anstey AV, Ingram JR, Limpens J, Flohr C, Spuls PI.
How to write a Critically Appraised Topic: evidence to underpin
routine clinical practice. Br J Dermatol 2017;177:1007e13.
None sought.
[2] Herbst KW, Harper L, Kalfa N, Committee ER. A brief descrip-
tion of study design. J Pediatr Urol 2018;14:135e6.
Funding

None declared.

Competing interests

None declared.