Professional Documents
Culture Documents
14 July 2009
Evidence-based Medicine for Surgeons
Imaging strategies for detection of urgent conditions in patients with acute abdominal pain:
diagnostic accuracy study
Authors: Laméris W, van Randen A, van Es WH, et al
Journal: British Medical Journal 2009;339:b2431doi:10.1136/bmj.b2431
Centre: Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
Several forms of imaging, of which ultrasonography and computed tomography (CT) are the most
often used, can assist in clinical decision making in patients who present with acute abdominal
BACKGROUND pain. Indiscriminate diagnostic imaging in the emergency department has been held responsible
for an increase in hospital costs. This concern calls for a rational, evidence-based approach to
imaging in patients with abdominal pain.
EBM-O-METER
Evidence level Overall rating Bias levels
Double blind RCT Sampling
Randomized controlled trial (RCT) Comparison
Trash Swiss Safe News-
Prospective cohort study - not randomized cheese worthy Measurement
Life's too Holds water
short for this Full of holes “Just do it”
Case controlled study
Interestingl | Novel l | Feasible l
Case series - retrospective Ethical l | Resource saving l
© Dr Arjun Rajagopalan
SAMPLING
Sample type Inclusion criteria Exclusion criteria Final score card
Simple random Non-traumatic Patients in shock Non-traumatic abdominal pain
abdominal pain of > Pregnant women
Stratified random Target ?
2 hrs and < 5 days'
Cluster duration Accessible ?
Age > 18 yrs
Consecutive Intended 1101
Convenience Drop outs 80
Judgmental Study 1021
COMPARISON
Randomized Case-control Non-random Historical None
Controls - details
Allocation details Included patients had a medical history, physical examination, and initial laboratory
investigations. A diagnosis based on clinical evaluation and laboratory investigation was
recorded. Thereafter, patients were investigated with a full structured imaging protocol,
including upright chest and supine abdominal plain radiography, abdominal ultrasonography,
and CT. After the physician in the emergency department had assessed the plain radiographs,
a new diagnosis was recorded.
Comparability -
Disparity There were no significant differences between the 80 patients who dropped out of the study
and the included patients in terms of age, sex, or time or type of presentation.
The fully paired study design, with all imaging tests in all patients and with the panel-based final diagnosis as the
reference standard, allowed a comparison of the diagnostic accuracy of multiple imaging strategies.
Comparison bias: All patients had, a priori, all tests; this is the element that makes the study stand out from others
that attempt to do the same but fail on the score that some, but not all, patients have each of the tests carried out.
MEASUREMENT
Measurement error
Device used Device error Observer error
Gold std.
Scoring
Blinding
Repetition
Protocols
Y ? N
An expert panel formed of two gastrointestinal surgeons and an abdominal radiologist with long term clinical experience
assigned a final diagnosis. The panel members had not been involved in the investigation or management of the
evaluated cases. Each panel member individually evaluated every case; data were presented in a standardized format,
including all available information collected during follow-up. Disagreements on the final diagnosis were resolved during
consensus meetings.
Measurement bias: The need to make quick decisions and move along always hampers the design of these studies
where expert opinions may not be available in short order and, necessarily, have to be carried out at a later date.
This study, addresses the issue of measurement bias squarely.
EDITOR'S NOTE: The paper is full of details and data that cannot be adequately reproduced within the limitations of
the the standardized format of ebm4s. Readers are strongly recommended to go through the full article.
© Dr Arjun Rajagopalan