An evidence-based nephrology column in the JN

Evidence-based medicine (EBM) combines clinical experience with the best available patient-centred medical knowledge. EBM is not restricted to randomised trials and meta-analyses. It involves finding the best studies (the best "external evidence") to answer the clinical questions we face in everyday clinical practice. This is a challenging framework where medical decisions absolutely cannot be based on a superficial or automatic approach to patient care. Interest in this approach is growing fast. The EB Nephrology Section of the Journal of Nephrology aims to help readers to update and extend their knowledge of the foundations, the tools and the products of EBM, with specific applications in the field of clinical nephrology.     

Evidence: What Is It,Where Do We Find It,and How Do We Use It?

The purpose of this paper is to review the history and rationale for evidence-based medicine (EBM). The development of EBM is briefly described, together with the pros and cons of evidence-based research, review techniques, and resources. The current status of EBM with regard to the treatment of overactive bladder (OAB) is also discussed. In short, EBM can be defined as the conscientious, explicit and judicious use of current best evidence to make decisions about the care of individual patients. The four main steps are: (1) formulate a clear question from a patient’s problem, (2) search the literature for relevant clinical articles, (3) evaluate and critically appraise existing evidence for its validity and usefulness, and (4) implement useful findings in clinical practice. The power of the evidence-based approach can be enhanced by the development of techniques such as systematic review and meta-analysis. However, although EBM allows us to use current best evidence to make decisions about patient care, the evidence gained from systematic review and meta-analysis only applies to an “average patient” and is not readily adaptable to issues such as etiology, diagnosis and prognosis.     

Evidence-based medicine for orthopedic practice

Evidence-based medicine (EBM) is regarded as a new paradigm in medical practice, equal in enormity to the human genome project. However, there is still much confusion and misunderstanding about the concept and content of EBM. It is often limited to searching the literature and reading papers, serving cost cutters, and suppressing clinical freedom. Some believe that the use of clinical guidelines or the managed care system intimidates doctors' discretion during clinical practice and that EBM is a fashionable tendency of a group of medical academics armed with epidemiological and statistical jargon. Medical practice is a lifelong, continuous process of self-learning, and it requires clinicians to keep up to date on various developments. EBM is our practice for integrating individual clinical expertise with the best available evidence when making decisions about our care for each patient. EBM is one answer for making it possible to cover most of our activities as orthopedic surgeons, from the daily practice of patient care to writing and reading scientific papers.     

Medical decision-making in membranous nephropathy: how to use limited clinical research evidence in patient management

Evidence-based medicine (EBM) originally referred to the use of a combination of clinical expertise and research evidence to make medical decisions, while carefully considering the patient's preference. In Japan, however, EBM has been misunderstood as the more abstract pursuit of acquiring research evidence and building medical guidelines. This review aims to summarize the available data regarding therapy for membranous nephropathy (MN), a field in which no consensus has been reached, and to discuss medical decision-making by using a decision tree in several model cases. In clinical practice, we have to consider both the risks and benefits of treatment. These are evaluated by their therapeutic effect (the rate of improvement, no change, or worsening) and by the patients' quality of life (QOL). This process is compatible with the essential concept of EBM.     

Evidence-based medicine in anesthesiology

By making the clinical decision making process explicit, conscious, and science based, we may avoid confusing opinion with evidence. EBM may help sharpen our critical appraisal skills and thus improve the way we practice, teach, and conduct research. Nevertheless, EBM will need to supplement rather than substitute for other approaches to patient care and teaching. EBM may better incorporate patients' values into clinical decision making, and this may be especially important in anesthesiology, where we are in need of valid evidence about important clinical issues such as preoperative testing and postoperative analgesia. By incorporating valid scientific evidence and patients' values into clinical decision making, we may improve patient outcomes. Outside of internal medicine, the literature suggesting that the practice of EBM improves outcomes is sparse, though increasing. Future studies to critically evaluate the practice of EBM in anesthesiology and critical care would be helpful.     

Exceptional medical circumstances: interest of an interhospital support strategy within the North Alps emergency trauma network

The Northern French Alps Emergency Network (RENAU) has a main objective the improvement of the quality of the care in the field of the emergency medical treatment. With this French medical system, we developed a procedure allowing the detachment of a medical-surgical team of the university hospital to help general hospital team in the event of immediate vital emergency situation with untransportable patient. We reported the successful implementation of this support strategy for a 51-year-old patient arrived in a hospital of the network in extremely serious hemodynamic shock due to an important hemorrhagic pericardial effusion with tamponnade 1 day after percutaneous closure of the patent foramen ovale (PFO).     

Care in the time of coronavirus: Ethical considerations in head and neck oncology

As COVID‐19 continues to challenge the practice of head and neck oncology, clinicians are forced to make new decisions in the setting of the pandemic that impact the safety of their patients, their institutions, and themselves. The difficulty inherent in these decisions is compounded by potentially serious ramifications to the welfare of patients and health‐care staff, amid a scarcity of data on which to base informed choices. This paper explores the risks of COVID‐19 incurred while striving to uphold the standard of care in head and neck oncology. The ethical problems are assessed from the perspective of the patient with cancer, health‐care provider, and other patients within the health‐care system. While no single management algorithm for head and neck cancer can be universally implemented, a detailed examination of these issues is necessary to formulate ethically sound treatment strategies.     

Commentary: how surgical audits can be used to promote the update of surgical evidence

Evidence-based medicine (EBM) is an important advance in health care. The Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S), the Royal Australasian College of Surgeons, has been at the forefront of promoting EBM in surgery by developing systematic reviews and managing surgical audits. In EBM, uptake of evidence is just as important as establishing the evidence. The prospective, long-term data collection of surgical audits on treatment processes and outcomes often have a high patient and surgeon coverage and make them extremely valuable as a tool for assessing the uptake of evidence. Surgical audits can be used: (i) to assess practice trends and the impact of systematic reviews or clinical guidelines on treatment practice, (ii) to identify the disparities in the uptake of evidence, and (iii) to promote further research on how to bridge evidence-practice gaps and to overcoming possible barriers for the evidence uptake. The information gathered through the audit data assessment on evidence-uptake can be used to improve evidence dissemination and identify possible barriers to the uptake of evidence.     

Principles of teaching evidence-based medicine

Teaching EBM is to impart the process of asking the question, acquiring and appraising the literature and applying it to the care of the patient, while weighing the risks, benefits and considering patient values. Teaching this process and its necessary content requires as with everything else, dedication, knowledge and practice. The best way to teach both patient care and EBM is by example.     

Palliative care in advanced cancer

Palliative care represents a new field among clinical approaches to patients with advanced or terminal cancer. The modern concept of palliative care can be considered in several ways: 1) the relationship between palliative care and primary treatments of cancer (surgery, radiotherapy or chemotherapy); 2) the treatment of symptoms and the relationship between symptom control and quality of life; 3) end-of-life care. With regard to the relationship between palliative care and primary cancer treatments, it is common opinion that a continuity of care is needed from diagnosis to the terminal phase of the disease, and oncology departments could represent the ideal dimension in which to fulfil this requirement. In a continuity-of-care setting, symptom control becomes vitally important to improve quality of life of the patient throughout all the stages of the disease. Moreover, support for the patient and his/her family during the terminal phase of the disease is one of the most important dimensions of palliative care. In addition, assistance provided during the last hours of life and support for the family after the patient's death represent the so-called global assistance, which is distinctive of palliative care.     

History and Development of Evidence-based Medicine

This article illustrates the timeline of the development of evidence-based medicine (EBM). The term “evidence-based medicine” is relatively new. In fact, as far as we can tell, investigators from McMaster’s University began using the term during the 1990s. EBM was defined as “a systemic approach to analyze published research as the basis of clinical decision making.” Then in 1996, the term was more formally defined by Sacket et al., who stated that EBM was “the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients.” Ancient era EBM consists of ancient historical or anecdotal accounts of what may be loosely termed EBM. This was followed by the development of the renaissance era of EBM, which began roughly during the seventeenth century. During this era personal journals were kept and textbooks began to become more prominent. This was followed by the 1900s, during an era we term the transitional era of EBM (1900–1970s). Knowledge during this era could be shared more easily in textbooks and eventually peer-reviewed journals. Finally, during the 1970s we enter the modern era of EBM. Technology has had a large role in the advancement of EBM. Computers and database software have allowed compilation of large amounts of data. The Index Medicus has become a medical dinosaur of the past that students of today likely do not recognize. The Internet has also allowed incredible access to masses of data and information. However, we must be careful with an overabundance of “unfiltered” data. As history, as clearly shown us, evidence and data do not immediately translate into evidence based practice.     

Practicing evidence-based dermatology: a short guide

Evidence-based medicine (EBM) is a paradigm for systematically collecting, evaluating, and applying the best information currently available to improve patient outcomes. Effective evidence-based practice requires defining an answerable, well-built question, systematically searching for the best current evidence, and appraising that evidence for validity. Essential components of EBM also require using our clinical expertise to integrate these data with our patients' characteristics, values, and circumstances; archiving the results of our EBM search; and evaluating the efficiency and effectiveness of the EBM process. Incorporating EBM to bring the best current evidence into our field can be mastered with practice and a commitment to apply the process daily.     

Research Pearls: How Do We Establish the Level of Evidence?

Evidence-based medicine (EBM) guidelines were first introduced in 1986 and were defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Level of evidence (LOE) stratifies publications from Level I to Level V and provides the foundation for EBM. Three questions should be asked when an LOE is assigned to a scientific article: (1) What is the research question? (2) What is the study type? and (3) What is the hierarchy of evidence? In cases in which LOE is not appropriate or relevant (basic science and laboratory-based investigations), a clinical relevance statement should be used. Unfortunately, study quality is not assessed by the assigned hierarchy level. LOE and EBM have increased the number of investigations published with better levels of evidence. As authors, reviewers, editors, and publishers, we desire a system that is consistent, effective, and reliable. Fortunately, the system has proven to have all of those attributes with good interobserver and intra-observer values. The increase in investigations with higher LOEs allows for more frequent use of EBM.     

Chondrosarcoma masquerading as cardiomyopathy

A 17-year-old male patient presented to his primary care provider with heart failure symptoms and was transferred to our hospital with the diagnosis of idiopathic cardiomyopathy. His workup identified a large mediastinal mass with right ventricular outflow obstruction, which was resected. The pathology of the mass was a low-grade chondrosarcoma. The patient currently remains disease free at 4 years.     

Evidence-based medicine in treatment and rehabilitation of spinal cord injured

The interest for evidence-based medicine (EBM) has grown, due to the enormous and exponentially increasing amount of medical literature published. EBM is 'the integration of best research evidence with clinical expertise and patient values'. The steps in the EBM process are (1) convert the need for information into a question; (2) find the best evidence; (3) critically evaluate the evidence; (4) integrate the critical appraisal with clinical expertise and the patient's unique biology, values, and circumstances; (5) evaluate the process and seek ways to improve effectiveness and efficiency. Both limitations related to the accumulation of evidence and the use and possible misuse of EBM in the health care are important to be aware of in the daily clinical environment. For use of EMB in treatment and rehabilitation of spinal cord injury MEDLINE is the most sensitive source for evidence due to its comprehensiveness and up to date maintenance, and the best pre-appraised evidence source is the Cochrane Library and Best Evidence. Clinical Practice Guidelines may provide a good summary of the actual evidence. In spite of limitations and dangers related to EMB, health care professionals generally agree that they should strive to incorporate evidence-based interventions into the multifaceted clinical decision-making process, including the individual patient values and circumstances.     

Successful management of fulminant pulmonary embolism using a novel portable extracorporeal life support system

A 46-year-old man presented to the emergency room with pain in his left leg, dyspnea, and general cyanosis. During examination he collapsed and required resuscitation. Under suspicion of pulmonary embolism, a new portable "click 'n run" extracorporeal life support system (LIFEBRIDGE-B(2)T [Medizintechnik AG, Ampfing, Germany]) was implanted by the femoral vessels under resuscitation within 15 minutes of presentation. The patient was stabilized, despite severe decompensation (pH, 6.8), and could be transferred for a computed tomographic scan, which confirmed massive pulmonary embolism. Still connected to the life support system, the patient was transferred to the operating room. After a pulmonary thrombectomy was performed, the patient recovered without any organ dysfunction. A portable emergency extracorporeal life support may change clinical practice in the treatment of patients with severe hemodynamic deterioration at emergency care hospitals.     

Evidence-based orthopaedics: is it possible?

EBM is referred to as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. This article describes the history and practice of evidence-based medicine.     

Evidence-based Surgery: A Passing Fad?

Recent years have witnessed the development of a new movement within health care: the promotion of “evidence-based medicine” (EBM). EBM is about integrating individual clinical expertise and the best external evidence derived from scientific research. Advocates claim that much medical practice is based too much on opinion and experience and insufficiently on research evidence. Their approach would increase the quality of care and its efficiency. This paper describes the principal steps in the evidence-based approach—systematic reviews of the literature and meta-analyses—and its shortcomings in surgery. These include the reliance of EBM on randomized trials, the lack of generalizability of scientific evidence to individual patients, the lack of attention to third party interests, the threat to the “art” of medicine, and the dangers of an oversimplistic approach. Although EBM clearly has a place, it does not have all the answers.     

The pros and cons of evidence-based surgery

Introduction: Evidence-based medicine (EBM) has been proposed as a new paradigm of practising medicine. However, an unproductive polarisation between supporters and opponents can make its unbiased assessment difficult. This review gives an overview of the arguments and discusses their surgeon-specific importance. Discussion: As EBM claims a position in the centre of medicine, it borders with other highly debated topics as, for instance, rationing and equity of care, doctor–patient interaction, medical research and education. Most arguments against EBM relate to its role in reducing health expenses by rationing healthcare. We think that the principles of EBM can be applied to make the inevitable process of rationing fair and reproducible. In addition, evidence-based surgery is criticised for interfering with patient individuality and physician autonomy, although this is a misunderstanding. Furthermore, the evidence-basis of EBM, in particular the randomised controlled trial (RCT) and systematic review, has been subject of discussion. Additionally, surgical research has its own inherent difficulties and, ultimately, some clinicians have doubted the practical feasibility of applying EBM at the bedside, because searching and critically appraising the literature is too difficult and time consuming. Conclusions: We believe that most critics consider EBM to be a potentially dangerous tool, because they fear it will be used against themselves. Thus, these conflicts only prove that EBM as a methodology may have a strong impact on solving them. As EBM has already made discernible progress, surgeons should not stand aside from these activities, which are bound to strongly influence healthcare in the next century. Received: 18 March 1999 Accepted: 23 August 1999