Evidence based medicine, by prof Badr Mesbah. Professor of pediatric, Suez canal university Lecture presented in Port said fourth neonatology conference, 24-25 October 2013, Port said, Egypt

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?

15. Study pyramid
Best
Worst

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....

17. Yalla, let’s try

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.

29. Thank you
Badr Mesbah