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Evidence based individual decision making

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how to fix the gap between evidence and practice

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Evidence based individual decision making

  1. 1. Evidence based individual decision making Dr. Mohammed Abdalla Damietta general hospital 2011 EBID
  2. 2. EBM is not only the best research evidence But the clinical expertise and the patient values are also integrated clinical expertise patient values best research evidence
  3. 3. 0 500000 1000000 1500000 2000000 2500000 Trials MEDLINE BioMedical MedicalArticlesperYear 5,000? per day 1,400 per day 55 per day A lot of
  4. 4.  Ia Evidence obtained from meta-analysis of randomised controlled trials.  Ib Evidence obtained from at least one randomised controlled trial.  IIa Evidence obtained from at least one well-designed controlled study without randomisation.  IIb Evidence obtained from at least one other type of well- designed quasi-experimental study.  III Evidence obtained from well-designed non- experimental descriptive studies, such as comparative studies, correlation studies and case studies.  IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
  5. 5. Which doctor do you want? William Osler, 1900 Smart young doctor
  6. 6. Which doctor do you want? Wise & experienced smart young doctor
  7. 7. Our practice must be based on evidence from good quality research, such as RCT, or SRv.
  8. 8. overall results may not be always applicable for patients seen in everyday practice. As they may differ in age, severity of illness, and presence of comorbidity.
  9. 9. • is the healthiest possible outcome for mother and baby.
  10. 10. IS EBM A QURAN ?
  11. 11. • “In God we trust” - But all others must show data…
  12. 12. Over the years, the prevailing medical wisdom can swing as dramatically as clothing fashions and gasoline prices. there are often serious disagreements… …
  13. 13. Vioxx: On September 30, 2004 heart attack and stroke . Fen phen and Redux: heart or lung damage Trasylol: 2007 , increased the risk of complications or death Propulsid: withdrawn from the market . Thiomersal controversy : some parents continue to be persuaded thiomersal is linked to autism
  14. 14. Bed rest during pregnancy for preventing miscarriage – There is insufficient evidence of high quality that supports a policy of bed rest in order to prevent miscarriage in women with confirmed fetal viability and vaginal bleeding in first half of pregnancy. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003576. DOI: 10.1002/14651858.CD003576.pub2. • > 80% still recommend bed rest to prevent miscarriage.
  15. 15. Progestogen for preventing miscarriage • There is no evidence to support the routine use of progestogen to prevent miscarriage in early to mid-pregnancy. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD003511. DOI: 10.1002/14651858.CD003511.pub2. • > 80% still recommend progestrone to prevent miscarriage.
  16. 16. Magnesium sulphate for preventing preterm birth in threatened preterm labour Magnesium sulphate is ineffective and its use Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD001060. DOI: 10.1002/14651858.CD001060. is associated with an increased mortality for the infant.
  17. 17. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus • magnesium sulphate therapy has a The neuroprotective role when given to women at risk of preterm birth for the preterm fetus. Cochrane Database of Systematic Reviews 2009, > 80% still don't use it
  18. 18. The considerable gap between what we know from research and what is done in clinical practice is well known
  19. 19. VBAC 2004 • most patients who have had a low-transverse uterine incision from a previous cesarean delivery and who have no contra-indications for vaginal birth are candidates for a trial of labor. Criteria for selecting candidates for VBAC include the following: • (1) one previous low-transverse cesarean delivery; • (2) clinically adequate pelvis; • (3) no other uterine scars or previous rupture; • (4) a physician immediately available throughout active labor who is capable of monitoring labor and performing an emergency cesarean delivery; • (5) the availability of anesthesia and personnel for emergency cesarean delivery.
  20. 20. VBAC Jan 2007 • New evidence is emerging to indicate that VBAC may not be as safe as originally thought.
  21. 21. VBAC rate was 5% in 1985. due to recommendations favoring TOLAC By 1996 VBAC rises to 28.3% . reports of uterine rupture and other complications during TOLAC also rises consequently.. By 2006, the VBAC rate had decreased to 8.5%. and the total cesarean delivery rate had increased to 31.1%
  22. 22.  In a 2010 consensus conference, (NIH) examined the safety and outcome of TOLAC and VBAC and factors associated with decreasing rates. The NIH panel recognized that TOLAC was a reasonable option for many women with a prior cesarean delivery and called on organizations to facilitate access to TOLAC. In addition, the panel recognized that “concerns over liability have a major impact on the willingness of physicians and healthcare institutions to offer [TOLAC]” .
  23. 23. Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality Antenatal corticosteroids should be given to all women at risk of iatrogenic or spontaneous preterm birth up to 34+6 weeks of gestation. April 1996 Evidence level 1++ Antenatal corticosteroids should be given to all women for whom an elective caesarean section is planned prior to 38+6 weeks of gestation. October 2010
  24. 24. Metroplasty versus expectant management for women with recurrent miscarriage and a septate uterus • Hysteroscopic metroplasty in women with recurrent miscarriage and a septate uterus is being performed in many countries to improve reproductive outcomes in women.This treatment has been assessed in non-controlled studies, which suggested a positive effect on pregnancy outcomes. However, these studies are biased due to the fact that the participants with recurrent miscarriage treated by hysteroscopic metroplasty served as their own controls. Until now, the effectiveness and possible complications of hysteroscopic metroplasty have never been considered in a randomised controlled trial.Taking this into account there is insufficient evidence to support this treatment in these women. Published Online: 15 JUN 2011 Cochrane
  25. 25. Aspirin or anticoagulants for treating recurrent miscarriage in women without antiphospholipid syndrome There is a paucity in studies on the efficacy and safety of aspirin and heparin in women with a history of at least two miscarriages without apparent causes other than inherited thrombophilia, the use of anticoagulants in this setting is not recommended. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD004734. DOI: 10.1002/14651858.CD004734.pub3.
  26. 26. Cervical assessment by ultrasound for preventing preterm delivery • Currently there is insufficient evidence to recommend routine screening of asymptomatic or symptomatic pregnant women with TVU CL. • future studies should include a clear protocol for management of women based on TVU CL results, so that it can be easily evaluated and replicated. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD007235. DOI: 10.1002/14651858.CD007235.pub2
  27. 27. If you received a notice from the ultrasound department that your patient—a primigravida at 21 weeks' gestation—has a cervical length of 19 mm with funneling. What are your management options if the patient reports no contractions or changes in vaginal discharge?
  28. 28. the same cervix, 20 seconds apart, without and with applying pressure funneling Dynamic change Without fundal pressure With fundal pressure
  29. 29. Cervical assessment by ultrasound for preventing preterm delivery • Currently there is insufficient evidence to recommend routine screening of asymptomatic or symptomatic pregnant women with TVU CL. • future studies should include a clear protocol for management of women based on TVU CL results, so that it can be easily evaluated and replicated. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD007235. DOI: 10.1002/14651858.CD007235.pub2
  30. 30. SHE HAS GOT PREGNANT BY ICSI. YOUR PATIENT IS 37YEARS AGE
  31. 31. Urgent, or therapeutic, cerclage often is recommended for women who have ultrasonographic changes consistent with a progressive shortening cervix or evidence of funneling. ACOG Practice Bulletin No. 48, appeared in the November 2003 issue Therapeutic cerclage is the short answer
  32. 32. conclusion
  33. 33. EBM firm adherence may blocks many things that could be useful if you're in need now. OR, the firm evidence you need now has not yet been developed - or has been developed, and hasn' t been published yet.
  34. 34. ( EBID ) IS EVIDENCE-BASED MEDICINE AS PRACTICED BY THE INDIVIDUAL HEALTH CARE PROVIDER. ( EBG ) IS THE PRACTICE OF EVIDENCE-BASED MEDICINE AT THE ORGANIZATIONAL OR INSTITUTIONAL LEVEL.
  35. 35. With today's emphasis on evidence-based medicine, it often is difficult to decide on an appropriate action, especially when conflicting reports abound.
  36. 36. Best research evidence ,Assessment of maternal risk ,quality of human judgment and decision making, are the gate for prevention of adverse pregnancy outcomes.
  37. 37. Thank you

how to fix the gap between evidence and practice

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