30 Maggio 2014 EBM sulle emolisi acute Primiano Iannone Medicina d’Urgenza e Pronto Soccorso Lavagna Editorials Evidence based medicine: what it is and what it isn't David L Sackett, William M C Rosenberg, J A Muir Gray, R Brian Haynes, W Scott Richardson BMJ 1996;312:71-72 (13 January) …Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom... “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” Ricerca prodotta Publication gap Ricerca pubblicata Retrievability gap Ricerca ritrovabile relevance gap Ricerca rilevante Internal validity gap Ricerca valida external validity gap Ricerca applicabile Good intention gap Ricerca integrata nelle decisioni cliniche Muir Gray JA. Evidence-based Healthcare. How to make health policy and management decisions. London: Churchill Livingstone 1997 1747 James Lind Medico di Bordo Vascello Salisbury IV Flotta di SMR 12 marinai con scorbuto (stesso stadio di malattia, fascia d’età e peso) Stessa parte della nave Gruppi di 2 marinai Aceto Acido solforico diluito Sidro Acqua di mare Noce moscata Due arance e un limone Ammiragliato britannico ordina che tutti i marinai di Sua Maestà assumano regolarmente succo di limone Fine XVIII secolo Scorbuto debellato tra le file della Marina Britannica Certainty Piramide delle evidenze Metodo EBM • • • • • • • Define the problem Search for evidences Critical appraisal of evidences Do evidences apply to my patients(s) ? Values and preferences of my patient(s) ? (Cost considerations cost conscious care) (Less is more !) 1.SCD Search for evidences (sickle cell anemia) • Google Scholar: 229.000 hits • PubMed [mh] : 242 RCTs, 180 SRs, 19 CPGs • Cochrane Library :41 CSRs, 9 Other SRs, 734 RCTs, 10 HTA, 16 EA • National Guideline Clearinghouse: 80 CPGs • Guidelines International Network: 7 CPGs IVIG, steroids Crisi iperemolitica in SCD Rituximab 2. HUS-TTP Search for evidences ( HUS_TTP) • Google Scholar: 62.400 (44000) hits • PubMed [mh] : 18 (12) RCTs, 36 (36) SRs, 6 (4) CPGs • Cochrane Library :1 CSR, 4 Other SRs, 58 RCTs, 5 HTA, 1 EA • National Guideline Clearinghouse: 2 (8) CPGs • Guidelines International Network: 0 (3) CPGs Plasma exchange- FFP (TTP) Supportive therapy + dialysis (HUS) Eculizumab (aHUS) Steroids TTP - HUS Rituximab (TTP) 3. NPH Search for evidences ( NPH) • Google Scholar: 20.700 hits • PubMed [mh] : 9 RCTs, 11 SRs, 2 CPGs • Cochrane Library :1 CSR protocol, 1 Other SR, 29 RCTs, 8 HTA, 1 EA • National Guideline Clearinghouse: 3 CPGs • Guidelines International Network: 1 CPG eculizumab HCT Steroids cyclosporin NPH Iron Folic acid Heparin, VKA Trasf androgens 4. AIHA Search for evidences ( AIHA) • Google Scholar: 56.700 hits • PubMed [mh] : 1 RCT, 13 SRs, 0 CPG • Cochrane Library :0 CSR, 0 Other SR, 16 RCTs, 0 HTA, 0 EA • National Guideline Clearinghouse: 3 CPGs • Guidelines International Network: 2 CPG rituximab steroids azathyoprine cyclophosphamide AIHA splenectomy mycophenolate Strong recommendations Weak recommendations uncertainty Livelli di evidenza e forza della raccomandazioni So, no Martini, no party ? DC shock per Fibrillazione Ventricolare Insulina per coma diabetico Imatinib per LMC Trasfusione per shock emorragico Vit B12 per anemia perniciosa A volte gli RCT sono inutili, non etici, o impossibili ……. EBM Areas of uncertainty Research needs and gaps If you think education is expensive, try ignorance !
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