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BET (best evidence topic)
Title
As a snappy question
(e.g. Are routine chest X-rays helpful in the management of febrile neutropenia?)
(e.g. A friendly, coryzal 5y
old girl with ALL attends with another episode of febrile neutropenia. According
to departmental protocol, her admission includes a chest x-ray. You wonder as to
the value of this routine irradiation.)
Three or four part clinical question
In a 5y girl with febrile
neutropenia [patient] does routine chest radiography [intervention] assist in
management decisions or diagnose occult pneumonia? [outcome]
Summary of searches performed. Start with secondary resources (e.g. Cochrane) and then pirmary resources. Describe search strategy used, hits found and hits relevant. Why exclude the others? Briefly�
(e.g. Secondary sources - nil
SumSearch - "neutropenia"
and "radiography" and filter "diagnosis" -> 67 individual
articles, 3 relevant.)
Use this table to fill in for your own studies. Each study should be accompanied by a longer, fuller, critical appraisal. The best way of doing this is using the Centre for Evidence-based Medicine (Oxford) CatMaker programme (www.cebm.net)
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Citation
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Study group
(Population
and comparisons)
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Study type |
Outcome
(one
line per outcome)
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Pick a key result, and try to give it as a useful number - e.g. NNT - with confidence intervals |
Comments
(one
line per study)
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Feusner
et al: J Clin Oncol 1988;
6: 1699-1702
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64 paediatric oncology
patients with 134 episodes of febrile neutropenia
Reference standard was
radiology opinion.
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Prospective cohort
(4)
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Prevalence of
"infectious" infiltrates
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3.0%
(95% CI 0.81% to 7.7%)
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'Infectious' infiltrate
was diagnosed partly by clinical findings - may exaggerate usefulness of
clinical signs
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Diagnostic usefulness of
"tachypnoea, chest pain or abnormal ausculation"
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LR+ 82
(95% CI 11 to 575)
LR- 0.0
(95% CI 0.0 to 0.19)
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||||
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Korones
et al: Cancer 1997; 80: 1160-1164
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54 paediatric oncology
patients with 108 episodes of febrile neutropenia
Reference standard was
radiology opinion.
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Prospective cohort
(4)
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Prevalence of pneumonia
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3.7%,
(95% CI 0.14% to 7.2%)
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Only 40/54 patients
received a chest radiograph
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Diagnostic usefulness of
"abnormal auscultatory findings, RR>20 when afebrile or O2 sats
<95% twice in 4 hours"
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LR+ 17.3
LR- 0
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||||
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131 paediatric oncology
patients with febrile neutropenia. Reference standard was radiology
opinion.
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Prospective cohort (4)
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Prevalence of pneumonia
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3.1%
(95% CI 0.7% to 7.8%)
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Only 128/131 patients
received radiographs
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|
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Diagnostic usefulness of
presence of respiratory signs
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LR+ infinite (lower 95%
CI 0.00)
LR- 0.5
(95% CI 0.25 to 1.0)
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Time for a short summation of the evidence, it's strengths and weaknesses, and any conclusions
(e.g. There is no good quality
study addressing the use of chest radiographs in uncomplicated febrile
neutropenia. Two of these studies are consistent with clinical feeling - lack of
abnormal signs or symptoms in children with febrile neutropenia rules out
pneumonia. The methodological weaknesses would tend to favour this - with one
study having clinical features as part of the reference standard, and the second
tending to fail to perform chest radiography on children without symptoms. The
third study only gives data on respiratory signs (ignoring symptoms) and has a
subsequently reduced sensitivity and improved specificity.)
Snappy one line answers to the questions posed
1.
Pneumonia was uncommon in children with febrile neutropenia (~3%)
2.
An absence of respiratory signs and symptoms made pneumonia very
unlikely.
First author with e-mail address, and brief designations only -- no letters after names!
(e.g. Clare Collins (Research
Fellow, Oxford Vaccine Group, Oxford) [clare.collins@paediatrics.ox.ac.uk],
Matthew Fenton (Registrar in Paediatric Oncology, John Radcliffe Hospital,
Oxford) and Bob Phillips (Junior Fellow, Centre for Evidence-based Medicine))