Evidence-based medicine

• using current best evidence conscientiously,

explicitly, and judiciously to make
decisions about individual patients
• intergrating individual clinical expertise
with the best available external clinical
evidence from systematic research
 Evidence-based medicine
Five Steps of the EBM-approach
1. Asking answerable clinical questions.
2. Searching for the evidence.
3. Critically appraising the evidence for its validity and
relevance.
4. Making a decision, by integrating the evidence with
your clinical expertise and the patient's values.
5. Evaluating the results of your performance.
 The aim of this excercise:
• To learn to ask answerable questions.
• To learn where to find the evidence for your
question.
• To learn how to find the evidence for your
question.
• To learn how to select the best quality
evidence for your question.
 Example:
• You admit a 75-year-old man with a stroke (left sided
weakness) who is having trouble with walking, feeding,
washing, and dressing himself. He has hypertension but it
is well controlled with a diuretic. He is otherwise well and
now that he is medically stable you decide to transfer him
to an intensive care unit after discussing it with him. His
family asks to see you because they are concerned about
this transfer. They live very close to the acute care hospital
and wonder why he can't stay on the general medical ward
where he is currently. You arrange to meet with him and
his family to discuss their concerns. In the meantime, you
decide to review the evidence for the use of intensive care
unit.
Convert your question to a search
strategy

How?
 Asking Answerable Clinical
Questions
Patient
(For which patient/population or problem do you need
information?)
Intervention
(What medical event do you need to study the effect of?)
Comparision
(What is the evidence that the proposed intervention
produces better or worse results than no intervention at
all, or a different type of intervention?)
Outcome
(What is the effect of the intervention?)
Where to find the evidence for
your question?

Books
Library databases
Online bibliographic databases
Cohrane Database of Systematic Reviews
 Searching for the Evidence
US National Library of Medicine:
24,000 journals
4,000 indexed in MEDLINE

Science Citation Index (SCI):

5,600 leading journals in different fields of science

Current Contents/Clinical Medicine:

1150 journals
 SEARCH DILEMMA……!!!
 Aim for (near) perfection by getting ALL evidence

 worry that
 significant evidence may be outside major databases
 Missed key document may downgrade usefulness of review
 Electronic sources of evidence
Source Availability Advantages Disadvantages
Critically http://cebm.jr2.ox.ac.uk Pre-appraised Only one study per
appraised www.eboncall.org summaries for a CAT; time limited;
topics (CATs) clinical question quality control

Best Evidence CD Rom Pre-appraised Limited coverage

summaries filtered
for clinical
relevance
Cochrane CD Rom, online from High-quality Limited coverage,
Library www.update-software.com systematic reviews time lag, ca be
/Cochrane/default.htm which cover a difficult to use
complete topic
Bibliographic CD Rom, online Original research Difficult to search
databases articles, up-to-date effectively, o
(MEDLINE, quality filtering,
CINAHL, etc) bibliographic text
 Databases
Database Coverage
CINAHL Nursing and allied health, health education, occupational and
physiotherapy, social services

EMBASE European equivalent of MEDLINE, with emphasis on drugs

and pharmacology

MEDLINE US database covering all aspects of clinical medicine,

biological sciences, education, technology, ad health related
social and information sciences

PsycLIT Psychology, psychiatry, and related disciplines, including

sociology, linguistics, and education
 Search strategies for MEDLINE

• Thesaurus searching
• Textword searching
 Define keywords

MeSH terms
Textwords
• Non-Hodgkin’s Lymphoma
• • Important keywords not
Non-Hodgkin Lymphoma
included in the MeSH
• Lymphoma, non-Hodgkin tesaurus
• Lymphoma, non-Hodgkin’s
 Check whether your keywords
are listed in MeSH

Consider text words

when a MeSH term does not exist
for your concept
 Boolean operators

– AND

– OR

– NOT
 Strategy of using Boolean operators:
first increase sensitivity, then specificity
1. One keyword concerning the patient
2. Another keyword concerning the patient
3. #1 OR #2
4. One keyword concerning the intervention
5. Another keyword concerning the intervention
6. #4 OR #5
7. One keyword concerning the outcome
8. Another keyword concerning the outcome
9. #7 OR #8
10. #3 AND #6 AND #9
 Sensitivity and Specificity

• Sensitivity – likelihood of retrieving

relevant items

• Specificity – likelihood of excluding

irrelevant items
 How to increase sensitivity?
1. Expand your search using (broader terms
in) the thesaurus.
2. Use a textword search of the database.
3. Use truncation and wildcards to catch
spelling variants.
4. Use Boolean OR to make sure you have
included all alteratives for the terms you
are after.
 Truncation

vaccin*
 vaccine, vaccines, vaccination

seizure$
 singular and plural
 Wildcards

gyn?ecology
 gynaecology, gynecology

randomi?*
 randomisation, randomization,
randomised, ...
 How to increase specificity?
1. Use thesaurus to identify more specific
headings.
2. Use more specific terms in textword
search.
3. Use Boolean AND.
4. Limit the search by publication type, year
of publication, patient’s age, etc.
 Limits
• Type of publication
• Age group
• Gender
• Year of publication
• Language
Identify the type of article

• Diagnosis
• Prognosis
• Therapy/prevention
• Harm/etiology
 Identify the type of research that is most
likely to answer your question

Question Study design Chances for finding

a systematic review?

Diagnosis cross-sectional 
Prognosis cohort 
Etiology/harm 1) cohort 
2) case-control
Therapy/prevention 1) randomized control trial 
2) non-randomized control trial
3) cohort
4) case-control
Patients' experiences qualitative studies 
 BASIC STEPS

1. formulate search question

2. build search strategy
3. select database
4. set parameters & run search
5. review search - focus/explode search
 Example:
• You admit a 75-year-old man with a stroke (left sided
weakness) who is having trouble with walking, feeding,
washing, and dressing himself. He has hypertension but it is
well controlled with a diuretic. He is otherwise well and now
that he is medically stable you decide to transfer him to an
intensive care unit after discussing it with him. His family
asks to see you because they are concerned about this
transfer. They live very close to the acute care hospital and
wonder why he can't stay on the general medical ward where
he is currently. You arrange to meet with him and his family
to discuss their concerns. In the meantime, you decide to
review the evidence for the use of intensive care unit.

What clinical questions could you ask?

 75-year-old man with a stroke and residual
Patient or Problem
weakness
Intervention admission to an intensive care unit
Comparison general care
Outcome functional status

In an elderly man with a stroke, does

Question admission to an intensive care unit decrease
the risk of death and dependency?
Keywords

• stroke and residual weakness

• intensive care unit
• general care
• functional status
 Limits

• Study design (Randomized control trial,

cohort, case control)
• Age group (45-80 years)
• Language (English)
Results:

?
Questions?
 I. FORMULATION OF
SEARCH QUESTION
… helps to
 obtain relevant answer
 understand question & concentrate mind
 identify relevant path of sources to find
information
better formulated the question,
more relevant the answer
 e.g …….CLINICAL QUESTION

 In patients with small, asymptomatic calyceal stones, is

prophylactic extracorporeal shockwave lithotripsy
(ESWL) better than a policy of observation ?


 DEFINING THE QUESTION-
BREAKING INTO CONCEPTS
 Patient / population (patient with condition x)
 Intervention/exposure/prognostic factor
 Comparison (usual care/no intervention)
 Outcome (did it work? which works better?)

Patient/problem Small, asymptomatic calyceal stones

Intervention Extracorporeal shockwave lithotripsy
Comparison, if any Observation
Outcome Stone free rate, requirement of additional
treatment, quality of life
 BASIC STEPS

1. formulate search question

2. build search strategy
3. select database
4. set parameters & run search
5. review search - focus/explode search
 Bear in mind:
1. Formulate a focused PICO question.
2. Define keywords.
3. Identify the type of article that is most likely to answer your type of
question: therapy, diagnosis, harm, etc.
4. Identify the type of research that is most likely to answer your type
of question: randomized control trial, cohort, cross sectional, case
control, etc. Always try to find systematic reviews, but be aware of
chances for success.
5. Check if your keywords are listed in MeSH; select MeSH terms that
represent your concepts.
6. Consider text words when a MeSH term does not exist for your
concept.
7. Combine concepts with Boolean operators (AND/OR/NOT). Refine
your search by limiting to age, sex, language, year of publication, etc.
8. Evaluate search results.
9. Use "Related Articles" link option.
Exercise 1:
• Your female patient, a long-time smoker,
have heard in a TV-show that the
acupuncture can help her to quit smoking.
She asks you if that is true.
Exercise 2:
• Four-year old boy diagnosed with bacterial
meningitis is admitted to your ward. Serology
tests indicate the infection with H. influenzae.
After taking blood samples for haemoculture, you
decide to treat your patient with antibiotics. You
know that in some cases bacterial meningitis can
lead to partial or total hearing loss, and you think
you have read somewhere that treatment with
dexamethasone can reduce the risk of hearing loss.
Exercise 3:
• Your friend, a student of Indology and
Oriental studies, claims there is no scientific
evidence that smoking marijuana reduces
driving abilities. How will you check
whether his claims are correct or not?
Exercise 4:
• 55-year old patient with a suspected aorthic
dissection underwent an ultrasound
examination, but the suspected diagnose
was not confirmed nor denied. What further
diagnostics would you ask for?
Exercise 5:
• Your patient read an article about the
benefits of daily use of aspirin in the
newspapers. He wants to take them. He has
peptic ulcer (and not Helicobacter pylori
infection) and you advise him not to take it.
He doesn’t suffer from any other diseases.
You want to convince him that daily use of
aspirin will badly damage his health.
Exercise 6:
• You prescribed Azithromycin for
pharyngitis to a preschool child. His mother
wants to know about the harmful effects of
Azithromycin.
Exercise 7:
• Your friend asked you about the efficiency
of herbal tea for treating constipation.
Exercise 8:
• Mother of a 16-year old boy comes to your
general practice office and asks you about
the adverse effects of ecstasy. She heard
that it can damage brain functions. She
thinks that her son is using ecstasy and she
is really concerned about his health. She
asks you for some evidence about the
adverse effects of ecstasy to convince him
to stop using it.
Exercise 9:
• Your 26-year-old patient has been suffering
from liver cirrhosis of unknown etiology for
ten years. She is hepatitis B and C negative.
She has to have a liver transplantation, but
she is afraid it won’t prolong her life and,
like all operations it is risky. She asks you
for advice if she should do it or not.
Exercise 10:
• Which therapy is better for reducing
psoriatic lesion? Naphthalanotherapy or
PUVA therapy?
Exercise 11:
• Your 17-year-old son broke his left arm. He
has a fracture of the radius in loco typico
without dislocation of bone fragments. At
the emergency room the doctor decided to
immobilize it. You are not sure if the
operation will be a better solution, so you
decided to check the references on the
PubMed.
Exercise 12:
• Your friend doesn’t want to vaccinate her 1-
year-old son against measles. She wants to
know what are his chances of getting this
infection. They live in Pennsylvania, United
States.
Exercise 13:
• Your patient has just delivered a baby. She
wants to know what would be the
consequences of her not breastfeeding her
child. She wonders if it can harm him or
her.