Evidence-based Medicine Approach Research Articles

Recommendations of the French society of rheumatology for the pharmacological management of knee osteoarthritis

Purpose: To establish on behalf of the French Society of Rheumatology (SFR) recommendations on pharmacological treatments (drugs and medical devices) for knee osteoarthritis (KOA) by an evidence-based medicine and expert opinion approach.

COMBINED APPROACH TO CLINICAL CLASSIFICATION OF CHRONIC PLACENTAL INSUFFICIENCY IN PERINATAL PERIOD: SETTING STANDARD IN DIAGNOSTIC AND OBSTETRIC MANAGEMENT

Objectives - to implement both a new clinical classification of chronic placental insufficiency (CPI) and a new complex rating scale based on calculation of an integral indicator of compensatory-adaptive placental reactions in order to improve perinatal outcomes. Material and methods. We examined 154 pregnant women with high risk of severe placental insufficiency (PI) in whom the markers of apoptosis, endothelial dysfunction, cell transformation and energy exchange were detected in gestation weeks 18-24 and 28-38 via blood analysis. It served the basis for development of the CPI severity rating scale. Diagnostic correlations in 359 pregnant women with various clinical and morphological manifestation of chronic PI allowed us to develop an original method of diagnosing the severity of this complication. Results and Discussion. The sequential changes in placenta in CPI ("placenta dysfunction" ^ "decompensated PI" ^ "progressive decompensated PI" ^ "acute PI") formed the basis of a new CPI clinical classification. The final indicator was calculated according to the complex point scale. The indicator's value from 1 to 3 points corresponds to placental dysfunction; the decompensated PI is diagnosed at 4 to 9 points; at 10 to 13 points - progressive decompensated PI; starting from 14 points - acute PI. The absence of PI is reported if the value of the final indicator scores zero. Conclusion. Setting a standard in the CPI diagnostic makes it 39% more accurate in severe PI, improves the perinatal outcomes by 60%, helps to avoid the disabling conditions in the neonates. High informativity and reliability of the developed PI severity rating diagnostic method was confirmed within the evidence-based medicine approach.

Reflecting on Evidence Based Medicine, Person Centered Medicine and Small Area Variations: how contemporary frameworks for medicine address (or not) the needs of the individual patient

Over the past few decades the medical literature has given much attention to three movements: Evidence Based Medicine (EBM), Person Centered Medicine (PCM) and Small Area Variations (SAV). Each claims to provide a framework for improving the care of individual patients. This paper examines why attention to the individual patient is important in the provision and delivery of healthcare and how each of these movements seek to address individual patient needs. We suggest that EBM, PCM and SAV all suffer from a number of issues that render their use as a framework to address individual patient needs inadequate. In the case of EBM, it is a reliance on (at best) population level study (e.g., clinical trials) that do not necessarily translate to individual patients. PCM appears to recognize the information requirements to care for individual patients, but is unclear on how that information can be obtained. Likewise, SAV is limited in that its methods do not discriminate between warranted and unwarranted variation and its reliance on the EBM approach in assessing what is the correct treatment for patients. This paper concludes that EBM, PCM and SAV are not solving the problem of how to provide care for individual patients. While we do not offer a solution here, it is only when we admit we do not have the answers to this problem that we can begin to look for a solution.

Need for a core outcome set on work participation

Both practitioners and patients need to know if an intervention is effective and safe. Following the evidence-based medicine (EBM) approach research questions about interventions should be structured according to PICO (Patient, Intervention, Comparator, Outcome).

Machine Learning and Evidence-Based Medicine.

Machine learning, which converts complex data into algorithms, challenges the traditional epidemiologic approach of evidence-based medicine. This commentary discusses intersections between these ap...

Do We Need to Change the Outlook?

Family Medicine is a complex branch by virtue of its nature. Broad in its perspective, it involves high proportion of poorly differentiated problems along with overlapping biological, psychological, and social factors.(1) EBM (Evidence Based Medicine) which originated in second half of 19th century, roused greater interest among health professionals especially during last decade (1). With time as medical knowledge grew, EBM was internationally accepted as gold standard for decision-making and standard for medical practice. It facilitated clinicians in providing up-to-date scientific evidence which in combination with clinical expertise was utilized in medical practice to achieve best possible outcomes (2). Evidence-based practice guidelines and EBM approaches are recognized as the core of today’s scientific thinking with randomized controlled trials (RCTs) being regarded as fundamental research response of EBM for healthcare (3). However, the most troubling aspect of EBM is that it provides the restricted view of evidence. As advocated since 1990s, it was based on the notion that medical practice was subjective and evidence should rather be prioritized on hierarchical system. To promote greater reliance on published literature, RCTs were introduced as a powerful tool for measuring effectiveness and safety of treatments. It argued that clinical judgment and mechanistic reasoning are less reliable forms of evidence in medicine (4,5). Despite EBM era, they still continues to exert influence, resulting in confusion and controversy.

Review of American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis.

Тиреотоксикоз представляет собой клинический синдром и встречается при разных заболеваниях, которые подразумевают разные лечебные подходы. В представленных клинических рекомендациях обсуждаются доказательные подходы к диагностике и лечению заболеваний, протекающих с тиреотоксикозом, разработанные Американской Тиреоидной Ассоциацией (АТА); при этом речь идет об обновленном документе, первая версия которого была опубликована в 2011 году. За прошедшие пять лет было опубликовано достаточно много исследований, что потребовало обновления рекомендаций. Все представленные положения ранжированы по силе и уровню доказательности, в соответствие с системой GRAD (Grading of Recommendations, Assessment, Development, and Evaluation Group). Основными проблемами, которые обсуждаются в рекомендациях, являются: обследование пациентов с тиреотоксикозом, лечение болезни Грейвса (БГ) при помощи тиреостатических препаратов, радиоактивного йода и хирургии; лечение многоузлового токсического зоба и токсической аденомы; лечение БГ у детей и подростков; субклинический тиреотоксикоз, эндокринная орбитопатия, а также диагностика и лечение других заболеваний, протекающих с тиреотоксикозом. По сравнению с 2011 годом изменились подходы к обследованию пациентов с тиреотоксикозом с целью установления его этиологии, лечение тиреотоксикоза при БГ тиреостатическими препаратами, лечение тиреотоксикоза во время беременности и к подготовке пациентов к оперативному лечению. Расширен раздел рекомендаций, посвященных более редким причинам тиреотоксикоза. В итоге для клинической практики было предложено 124 рекомендации.

“Watch Britain”: Movement Education, Transnational Exchanges, and the Contested Terrain of Physical Education in Mid-Twentieth-Century Canada

Abstract The notion that exercise is medicine dominated Canadian physical education in its nineteenth-century inception and continued to circulate through fitness discourses despite the introduction of movement education in the mid-twentieth century, which offered more progressive methods of child-centered teaching. Canada’s approach to physical education in the postwar decades was affected by important transatlantic influences, not only in matters of national fitness but through numbers of émigrée female physical educators from Britain who played a significant role in the transfer and exchange of professional practices. Arriving in British Columbia—the end of the railway line—in the late 1950s and ’60s, these women promoted movement education and gained considerable traction in schools and colleges. Ultimately, however, an increasingly gendered discourse pitted the female-centered tradition of child-centered movement education against a growing appetite for competitive sport-skill-based forms of physical education and biopedagogical interventions supported by an evidence-based medicine approach.

The most appropriate therapeutic strategy for acute lower respiratory tract infections: a Delphi-based approach

Lower respiratory tract infections (LRTIs) cause high morbidity and mortality worldwide. Empiric therapy often base the choice of antibiotic treatment on antibacterial spectrum of the agent rather than on its pharmacological properties or the pathogen resistance profile. Inappropriate prescribing leads to therapeutic failure and antibiotic resistance, with increasing direct and indirect health costs. A consensus on appropriate prescribing in LRTI therapy was appraised by this Delphi exercise, based on a panel of 70 pulmonologists, coordinated by a Scientific Committee of nine experts in respiratory medical care. Full or very high consensus was reached on several issues, including the role of oral cephalosporins in first-line treatments of LRTIs and the appropriateness of cefditoren, with balanced spectrum and high intrinsic activity, in LRTI treatment. Evidence-based medicine approach and a comprehensive process of disease management, from diagnosis to therapy and follow-up, should guide antibiotic prescribing.

Evidence-based Surgery of Aortic Regurgitation: Results of a Questionnaire in German-speaking Countries.

evidence-based medicine (EBM) approaches have reached broad acceptance, both in conservative and surgical disciplines. The aim of this study is to clarify the role of EBM in a rare condition of aortic regurgitation (AR) with surgical indication. A purpose-built Internet-based questionnaire was sent to 607 cardiovascular surgeons in Germany, Austria, and Switzerland. A virtual 64-year-old patient's medical history was presented, including two ultrasound images and one computed tomography scan, showing a 58-mm aortic root aneurysm and a severe trileaflet regurgitant aortic valve. Participants had to choose their preferred therapeutic strategy from a list. Additionally, demographics including nationality, the center size, and the frequency of similar types of patients referred to their departments were collected. Of 607 questionnaires, 100 were returned (16%). One participant was excluded due to conflicting answers. Most surgeons (n = 84; 84%) chose a valve-sparing root replacement (VSRR). A Bentall procedure was preferred by 13 surgeons (13%). Two surgeons voted for aortic valve replacement combined with partial root resection. The decision-making process was not significantly influenced by center size, nationality, or frequency of patients. Applying the current guidelines to our virtual study patient, 84% of participants acted accordingly choosing VSRR. Remarkably, 14% of these surgeons see less than 10 and 43% see not more than 20 comparable patients per year. Since the guidelines reserve VSRR for competent centers, those numbers as well as the guidelines themselves should be further discussed.

An Evidence-Based Medicine Approach to Antihyperglycemic Therapy in Diabetes Mellitus to Overcome Overtreatment.

Overtreatment is pervasive in medicine and leads to potential patient harms and excessive costs in health care. Although evidence-based medicine is often derided as practice by rote algorithmic medicine, the appropriate application of key evidence-based medicine principles in clinical decision making is fundamental to preventing overtreatment and promoting high-value, individualized patient-centered care. Specifically, this article discusses the importance of (1) using absolute rather than relative estimates of benefits to inform treatment decisions; (2) considering the time horizon to benefit of treatments; (3) balancing potential harms and benefits; and (4) using shared decision making by physicians to incorporate the patient's values and preferences into treatment decisions. Here, we illustrate the application of these principles to considering the decision of whether or not to recommend intensive glycemic control to patients to minimize microvascular and cardiovascular complications in type 2 diabetes mellitus. Through this lens, this example will illustrate how an evidence-based medicine approach can be used to individualize glycemic goals and prevent overtreatment, and can serve as a template for applying evidence-based medicine to inform treatment decisions for other conditions to optimize health and individualize patient care.

Challenges of integrating evidence into health policy and planning: linking multiple disciplinary approaches.

To explore the challenges that arise through the multidisciplinary nature of evidence informed policy making (EIPM). Type of program or service: Education and practice for EIPM. This article summarises and compares four disciplinary approaches to EIPM with highly contrasting starting points: behavioural science, policy science, critical theory and intervention research. Key insights and theories are highlighted to provide a gateway into each, and to complement what is already known about the evidence needs of policy makers in terms of high-quality, timely and well-communicated research evidence. The extension of the evidence based medicine approach to EIPM has created interest in the processes of use of evidence in health policy and planning. Research in this field has spanned multiple disciplines; however, the disciplines use very different research methods and begin with different basic assumptions. Thus, despite the multidisciplinary nature of EIPM, true interdisciplinary research and action remain a challenge. We conclude with a set of key questions that can be used as a gateway to interdisciplinary EIPM in the future.

Selective intracellular inhibition of signalling pathways - new direction in systematic treatment of psoriasis patients

This article presents current data from publications on new direction in systematic treatment of patients with psoriasis with help of "small molecules" that act intracellularly, selectively inhibiting signaling pathways responsible for production of key pro- and anti-inflammatory mediators that play an important role in the pathophysiology of psoriasis. We discuss key issues that refer to immunopathogenesis of psoriasis, targeted influence of "small molecules" on key components of innate and adaptive immune system of patients psoriasis. This article presents results of the studies performed according to the evidence-based medicine approaches, on the efficiency and safety of apremilast - the first and only current selective inhibitor of intracellular phosphodiesterase 4 - for treating medium-severe and severe psoriasis, including patients with problematic localizations of dermatosis (psoriasis of scalp pilar part, palms, soles, nail plates), as well as in the long run. It is shown that continuous apremilast therapy for the term of 52-156 weeks was accompanied by a significant decrease in prevalence and severity of psoriasis. Adverse events were recorded rarely, they were mild, and frequency of serious adverse reactions was comparable to placebo.

2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis.

Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition. The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded. One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

Evidence-Based Medicine: A Genealogy of the Dominant Science of Medical Education

Debates about how knowledge is made and valued in evidence-based medicine (EBM) have yet to understand what discursive, social, and historical conditions allowed the EBM approach to stabilize and proliferate across western medical education. This paper uses a genealogical approach to examine the epistemological tensions that emerged as a result of various problematizations of uncertainty in medical practice. I explain how the problematization of uncertainty in the literature and the contingency of specific social, political, economic, and historical relations allowed the EBM approach to become a programmatic and pedagogical focus of the Faculty of Medicine at McMaster University and beyond.

Les complaintes du carabin. Modèle pour un raisonnement clinique pratique

The teaching of clinical reasoning process combines, on the one hand the learning of theoretical knowledge to provide medical representation organized for specific actions to medicine, and on the other hand the transmission of a clinical practice based on these representations. However, the use of theoretical knowledge to clinical practice remains a challenge for the medical student. The concept of clinical reasoning process would then remain at the confluence of the theoretical knowledge and the clinical practice, which could not be derived completely from the theoretical knowledge. This article will thus try to give some keys to solve the problem of clinical reasoning learning. The first part will address the different medical reasoning modalities, around two main dichotomies: the dichotomy between a systematic and an oriented clinical data collection, the dichotomy between analytical and not analytical (intuitive) reasoning. The second part will address some fundamental medical representations that allow structuring the clinical reasoning process around theoretical concepts closer to the clinical action. The proposed representations are: the diagnosis (and the associated concept of syndromes and contextual data), the prognosis (and the associated concepts of disease progressive modalities, and of seriousness and severity) and the therapeutic (and the associated concepts of Evidence-Based Medicine and patient-centered approach).

Therapeutic Management of Feline Chronic Gingivostomatitis: A Systematic Review of the Literature.

Feline chronic gingivostomatitis (FCGS) is a disease characterized by protracted and potentially debilitating oral inflammation in cats, the etiology of which is currently unknown. The purpose of this review is to apply an evidence-based medicine approach to systematically review and critically evaluate the scientific literature reporting the outcome of medical and surgical management of FCGS. Those articles meeting inclusion criteria were reviewed and assigned an “Experimental Design Grade” (EDG) and an “Evidence Grade” (EG) in order to score relative strength of study design and produced data. Studies were evaluated and compared, especially highlighting the treatments, the outcomes, and the therapeutic success rates. This review found a lack of consistency between articles’ data, rendering direct comparison of results unreliable. The field of FCGS research, and ultimately patient care, would benefit from standardizing studies by adopting use of a consistent semi-quantitative scoring system and extending follow-up duration. Future researchers should commit to large prospective studies that compare existing treatments and demonstrate the promise of new treatments.

Examining the Influence of Context and Professional Culture on Clinical Reasoning Through Rhetorical-Narrative Analysis.

According to the dual process model of reasoning, physicians make diagnostic decisions using two mental systems: System 1, which is rapid, unconscious, and intuitive, and System 2, which is slow, rational, and analytical. Currently, little is known about physicians' use of System 1 or intuitive reasoning in practice. In a qualitative study of clinical reasoning, physicians were asked to tell stories about times when they used intuitive reasoning while working up an acutely unwell patient, and we combine socio-narratology and rhetorical theory to analyze physicians' stories. Our analysis reveals that in describing their work, physicians draw on two competing narrative structures: one that is aligned with an evidence-based medicine approach valuing System 2 and one that is aligned with cooperative decision making involving others in the clinical environment valuing System 1. Our findings support an understanding of clinical reasoning as distributed, contextual, and influenced by professional culture.

From Drug Literature Evaluation to Evidence-Based Medicine: Transforming the Focus of a First Year Pharmacy Curriculum

This case study describes a longitudinal curricular sequence implemented to teach evidence-based medicine (EBM) skills. The longitudinal sequence is innovative in its approach, design, and assessment of EBM. This approach moves away from the conventional strategy of teaching drug information and drug literature evaluation as stand-alone courses and instead embraces the EBM Framework and its use in the context of authentic problem solving. The EBM Framework—Ask, Acquire, Appraise, and Apply—was used as the basis for defining seven EBM skills. These skills were targeted in the evidence-based, integrated design of 17 learning episodes delivered with eight faculty members through six courses in the first year. Student perceptions of relevance of EBM and performance on assessments and learning activities throughout the sequence suggest that integrating EBM across the first year of the curriculum is an effective strategy for teaching EBM skills. Three themes emerged from analysis of the data and experience, including the need for: a strong teaching team, a whole task approach with a focus on solving authentic problems, and care in interpreting the progression of assessments and patterns of student performance. Through instructor observations and peer review, the longitudinal sequence has been refined and has had an impact on the rest of the curriculum.
 
 Type: Case Study

Primary and secondary transsexualism, really?

IntroductionTranssexualism suffers from several definitions that evolve across time. Therefore, some discrepancies appear progressively in regard of evidence-based medicine and psychological approaches as sexo-analysis.ObjectivesIn our present study, we test if “primary” or “secondary” transsexualism defines in accordance with sexo-analysis definitions will be reliable with the pathology course.AimsClarify the definition of transsexualism to obtain a better understanding of this trouble and perhaps to change psychological approaches of gender disorders.MethodsNine transsexual male-to-female (MtF) aged between 25 to 65 were voluntary recruited. They were diagnosed by a psychiatrist. We adapted the GID scale to measure the lifetime process. Descriptive statistics were reported. Results are expressed as mean ± standard deviation.ResultsAge of the group is 41 ± 12. All subjects were treated by hormone therapy. One of them was surgical reassigned. All subjects reported a persistent feeling to be a woman across their entire life. None showed a decreased female feeling during a part of their life or a brutal apparition of this trouble during the adult period.ConclusionsIn regards of our preliminary results, we concluded that secondary transsexualism should be redefined and was probably induced by sociocultural aspects. Our results are limited by amount of subjects and should be confirmed by a large population included MtF and FtM people.Disclosure of interestThe authors have not supplied their declaration of competing interest.