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Pediatrics Department and Clinical Epidemiology Unit
Faculty of Medicine, Suez Canal University

Introduction to

Evidence based medicine
(EBM)

Badr Mesbah
What is evidence-based medicine?

• …an approach to practicing medicine in which
the clinician is aware of the evidence in support
of clinical practice, and the strength of that
evidence.
What is evidence-based medicine?

• Combines your clinical knowledge with your
knowledge of your patient, with evidence from
the literature
What is evidence-based medicine?
• Evidence-based medicine is the integration of best
research evidence with clinical expertise and
patient values”
Patient
Concerns
EBM
Clinical
Best research
Expertise
evidence

Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2
Why EBM?
• Daily need for information
• Inadequacy of traditional sources of information
• Disparity between our diagnostic skills and clinical
judgment vs. up-to-date knowledge and clinical
performance
• Develop skills for lifelong learning
Steps to practice EBM
• Convert clinical questions into a searchable
format.
• Search for evidence.
• Critically assess the information for validity and
usefulness.
Steps to practice EBM
• Apply the information in clinical practice.
• Evaluate the performance of the information in
clinical practice.
• Discover areas where more research is needed
The first step of EBM
• Convert a clinical situation into a searchable, (and
hopefully answerable) question using

PICO
• PATIENT
• INTERVENTION
• COMPARISON
• OUTCOME
PICO

Patient
Intervention
Comparison
Outcome

“Patient” refers to the
person presenting with
the problem, or more
simply, to the problem
itself. Both concepts
are important in
searching.
PICO

Patient
“Intervention” refers to
the action taken in
Intervention response to the
problem. This is often
Comparison a drug or surgical
procedure, but it can
Outcome
take many forms
PICO

Patient
“Comparison” refers to
Intervention the benchmark against
Comparison which the intervention
is measured. Often it
refers to another
Outcome

treatment, no
treatment, or a placebo
PICO

Patient
Intervention
Comparison
Outcome

“Outcome” refers to the
anticipated result of the
intervention.
Search for evidence
• Types of Information Databases
• Primary sources
– MedLine
– Require more work to validate

• Secondary sources
– Cochrane, Best Evidence, InfoPoems
– Already reviewed - less work to validate
– Limited amount of information studied
How good is the evidence?
- Is it from a peer-reviewed journal?
 - Is the location and patients similar to mine?
- Sponsored by an organization that may influence
the study design or results?
- Will the information, if true, have an impact on
my patients and practice?
Study pyramid
Best

Worst
Levels of Evidences
• (I-1): a well done systematic review of 2 or more
RCTs
• (I-2): a RCT
• (II-1): a cohort study
• (II-2): a case-control study
• (II-3): a dramatic uncontrolled experiment
• (III): respected authorities, expert committees,
etc..
• (IV): ...someone once told me....
Yalla, let’s try
Clinical Scenario
A family came with their 3 days old
baby:
We want to perform circumcision to our
baby as his pain perception is minimal at
this age. You know that this is not true
and wondered about the best method of
pain relief in this situation
Question (PICO)
Patients:

Newborn undergoing
circumcision

Intervention: Pharmacological and/or
nonpharmacological
interventions
Comparison:

No intervention

Outcome:

Pain relief
Question

• In newborn infants undergoing circumcision
(population), which pharmacological and/or nonpharmacological interventions (intervention)
provide the best pain relief (outcome)?
Search for evidence
Intervention

Type of evidence

Results

Comments

Paracetamol
versus placebo

Systematic reviews

Paracetamol is
effective in
reducing
postoperative pain

Benefit was noted
only 6 hours after
surgery

Dorsal penile nerve
block versus no
intervention

Systematic review

Dorsal penile nerve
block is effective in
reducing pain
response

Bruising and/or
hematoma can
occur at the site of
injection
Search for evidence
Intervention

Type of evidence

Results

Comments

Ring block versus
no intervention

Systematic reviews

Ring block is
effective in
reducing pain
response

EMLA versus no
intervention

Systematic review

EMLA decreases
pain response

Further studies of
ring block are
required to
demonstrate any
superiority in
efficacy and
safety compared to
dorsal penile nerve
block
EMLA cannot be
recommended
over local regional
nerve block
Search for evidence
Intervention

Type of evidence

Results

Comments

Sucrose with or
without pacifier
compared to water
with or without
pacifier

Systematic reviews

Oral sucrose with
or without pacifier
is effective in
reducing the pain
response

Sucrose is not as
effective as
dorsal penile nerve
block

Swaddling versus
no
intervention

Systematic review

Swaddling reduces
behavioral
response
Current best practice for reducing pain associated
with circumcision
• Administer 10–15 mg kg of acetaminophen within
2 hours before the procedure and every 4–6 hours
for 24 hours after the procedure.
• Offer a sucrose-dipped pacifier to the newborn
before the dorsal penile nerve block, during the
circumcision procedure, and after
Current best practice for reducing pain associated
with circumcision

• Administer dorsal penile nerve block using lidocaine
• Swaddle the infant’s upper body during the
circumcision
Future research needs
• Further research is required to find ways to
reduce the exposure of newborns to painful
stimuli and to refine the pain management
for unavoidable, painful, medically indicated
procedures..
Do developing countries really need EBM?
Definitely yes, more so than in Western world
• Limited resources even more precious
• Waste even more unacceptable when needs are
great and budgets small
• Often there is evidence that current practices
don’t work and should be abandoned
• Best evidence doesn’t mean perfect evidence,
rather best available; solutions need to be
appropriate for setting and resources
Summary
• Evidence-based medicine is a systematic
approach to use up to date information in the
practice of medicine
• Skills are needed to integrate the available
evidence with clinical experience and patient
concerns
• Application and evaluation of EBM skills will
provide a framework for life-long learning.
Thank you

Badr Mesbah

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  • 1. Pediatrics Department and Clinical Epidemiology Unit Faculty of Medicine, Suez Canal University Introduction to Evidence based medicine (EBM) Badr Mesbah
  • 2. What is evidence-based medicine? • …an approach to practicing medicine in which the clinician is aware of the evidence in support of clinical practice, and the strength of that evidence.
  • 3. What is evidence-based medicine? • Combines your clinical knowledge with your knowledge of your patient, with evidence from the literature
  • 4. What is evidence-based medicine? • Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” Patient Concerns EBM Clinical Best research Expertise evidence Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2
  • 5. Why EBM? • Daily need for information • Inadequacy of traditional sources of information • Disparity between our diagnostic skills and clinical judgment vs. up-to-date knowledge and clinical performance • Develop skills for lifelong learning
  • 6. Steps to practice EBM • Convert clinical questions into a searchable format. • Search for evidence. • Critically assess the information for validity and usefulness.
  • 7. Steps to practice EBM • Apply the information in clinical practice. • Evaluate the performance of the information in clinical practice. • Discover areas where more research is needed
  • 8. The first step of EBM • Convert a clinical situation into a searchable, (and hopefully answerable) question using PICO • PATIENT • INTERVENTION • COMPARISON • OUTCOME
  • 9. PICO Patient Intervention Comparison Outcome “Patient” refers to the person presenting with the problem, or more simply, to the problem itself. Both concepts are important in searching.
  • 10. PICO Patient “Intervention” refers to the action taken in Intervention response to the problem. This is often Comparison a drug or surgical procedure, but it can Outcome take many forms
  • 11. PICO Patient “Comparison” refers to Intervention the benchmark against Comparison which the intervention is measured. Often it refers to another Outcome treatment, no treatment, or a placebo
  • 12. PICO Patient Intervention Comparison Outcome “Outcome” refers to the anticipated result of the intervention.
  • 13. Search for evidence • Types of Information Databases • Primary sources – MedLine – Require more work to validate • Secondary sources – Cochrane, Best Evidence, InfoPoems – Already reviewed - less work to validate – Limited amount of information studied
  • 14. How good is the evidence? - Is it from a peer-reviewed journal?  - Is the location and patients similar to mine? - Sponsored by an organization that may influence the study design or results? - Will the information, if true, have an impact on my patients and practice?
  • 16. Levels of Evidences • (I-1): a well done systematic review of 2 or more RCTs • (I-2): a RCT • (II-1): a cohort study • (II-2): a case-control study • (II-3): a dramatic uncontrolled experiment • (III): respected authorities, expert committees, etc.. • (IV): ...someone once told me....
  • 18. Clinical Scenario A family came with their 3 days old baby: We want to perform circumcision to our baby as his pain perception is minimal at this age. You know that this is not true and wondered about the best method of pain relief in this situation
  • 19. Question (PICO) Patients: Newborn undergoing circumcision Intervention: Pharmacological and/or nonpharmacological interventions Comparison: No intervention Outcome: Pain relief
  • 20. Question • In newborn infants undergoing circumcision (population), which pharmacological and/or nonpharmacological interventions (intervention) provide the best pain relief (outcome)?
  • 21. Search for evidence Intervention Type of evidence Results Comments Paracetamol versus placebo Systematic reviews Paracetamol is effective in reducing postoperative pain Benefit was noted only 6 hours after surgery Dorsal penile nerve block versus no intervention Systematic review Dorsal penile nerve block is effective in reducing pain response Bruising and/or hematoma can occur at the site of injection
  • 22. Search for evidence Intervention Type of evidence Results Comments Ring block versus no intervention Systematic reviews Ring block is effective in reducing pain response EMLA versus no intervention Systematic review EMLA decreases pain response Further studies of ring block are required to demonstrate any superiority in efficacy and safety compared to dorsal penile nerve block EMLA cannot be recommended over local regional nerve block
  • 23. Search for evidence Intervention Type of evidence Results Comments Sucrose with or without pacifier compared to water with or without pacifier Systematic reviews Oral sucrose with or without pacifier is effective in reducing the pain response Sucrose is not as effective as dorsal penile nerve block Swaddling versus no intervention Systematic review Swaddling reduces behavioral response
  • 24. Current best practice for reducing pain associated with circumcision • Administer 10–15 mg kg of acetaminophen within 2 hours before the procedure and every 4–6 hours for 24 hours after the procedure. • Offer a sucrose-dipped pacifier to the newborn before the dorsal penile nerve block, during the circumcision procedure, and after
  • 25. Current best practice for reducing pain associated with circumcision • Administer dorsal penile nerve block using lidocaine • Swaddle the infant’s upper body during the circumcision
  • 26. Future research needs • Further research is required to find ways to reduce the exposure of newborns to painful stimuli and to refine the pain management for unavoidable, painful, medically indicated procedures..
  • 27. Do developing countries really need EBM? Definitely yes, more so than in Western world • Limited resources even more precious • Waste even more unacceptable when needs are great and budgets small • Often there is evidence that current practices don’t work and should be abandoned • Best evidence doesn’t mean perfect evidence, rather best available; solutions need to be appropriate for setting and resources
  • 28. Summary • Evidence-based medicine is a systematic approach to use up to date information in the practice of medicine • Skills are needed to integrate the available evidence with clinical experience and patient concerns • Application and evaluation of EBM skills will provide a framework for life-long learning.