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11 Cards in this Set

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Hierachy of Evidence..from least to greatest
1. Basic Science/Animal→Case Reports→Case Series→Case Control Study→Cohort Study→Randomized Control Trial(ACAS,NASCET)→Systematic Review(Chaturvedi)→Meta-Analysis
Hills Criteria 1-3:
1 Strength of Association.
2 Temporal Relationship
3 Dose Response Relationship
1. Statistical indication of causality
2. A must come before B to indicate causality.
3. Linear relationship BUT not necessary for causality.
ACAS study shows...
*Carotid Disease leads to Stroke
*Statistical Correlation displayed
*Macular Hole in the left eye-Asymptomatic no problem
*Men did better than women
NASCET study shows...
*Carotid Disease leads to Stroke
*Statistical Correlation displayed
*Dose-Response relationship
*50-74% carotid stenosis on the LEFT- MODERATE severity
*>75% carotid stenosis on the RIGHT-SEVERE
*Men did better than women
Hills Criteria 4-6
4. Consistency
5. Plausibility
6. Consideration of Alternate Explanations
4. Same result regardless of study/population-european agreed w/ american
5. Agrees w/ current understanding of pathology-by extension from coronary disease
6. Extent to which other options were considered-self evident process
Hills Criteria 6-8
6.Experiment
7.Specificity
8.Coherence
6. condition can be altered by experiment-surgical intervention
7. single cause produces and effect. absence of which does not negate causality-specific for symptomatic disease
8. compatible association with existing theory and knowledge-coherence was met
Name possible limits to study
Studies were old. Results aren't generalizable
Other factors: age, type of event, other comorbidities
1. older patients have better results(above 80 not studied)
2. Retinal TIA had less benefit in moderate grade disease
3. worse outcome w/ DM, high Dias BP, no hx of MI, contralateral coratid occlusion, stroke on CT/MR, left sided disease; better outcome-recent stroke of TIA
What Should you do?
1. Scenario One: moderate grade stenosis and retinal TIA/STROKE
2. Scenario Two: atypical event with symptomatic stroke, however, and severe stenosis
3. Scenario Three: asx moderate grade on left and severe grade on right.
1. Scenario One: moderate grade stenosis and retinal TIA/STROKE: Operate
2. Scenario Two: atypical event with symptomatic stroke, however, and severe stenosis: Operate
1. Scenario Three: asx moderate grade on left and severe grade on right: Operate on right if patient desires (otherwise, f.u carotid ultrasound in 6-12 months)-no ‘right answer’
For each clinical issue state the best type of study.
1. Therapy
2. Diagnosis
3. Etiology/Harm
4. Prognosis
5. Prevention
1. Randomized Cntrl Study
2. Prospective comparison of a new test to a Gold Standard(blinded)
3. RCT
4. Cohort
5. RCT
State the EBM Levels
I.
II.
III.1
III.2
III.3
IV
Evidence from....
I. Systematic review of all RCTs
II. One properly designws RCT
III.1 Well designed psuedo-randomized RCT
III. 2 Comparative study w/ concurrent controls and allocation not randomized(cohort study, case-control analytic study or interrupted time series with a control group
III.3 Comparative study with historical control, two or more single arm studies or interrupted time series without a parallel control group
IV. case series either post test or post test and pre test