Evidence-Based Medicine

Dr. Nadira Abbas Al-Baghli

 ?What is evidence
Research

Are all research valid and relevant?

EBM checks the validity and relevance.

 EBM
Using current best evidence in decision
making in medicine + the expertise of
decision makers+ expectations and values
of Patients/ people.
Pt e ch. Pain resulting from terminal
cancer. She has come to term with her
condition. She wishes to receive only
palliative treatment. The pt develop
pneumoccocal pneumonia. Now evidence
that antibiotic therapy reduces mortality
from pneumoccocal pneumonia strong.
85- year old man with sever dementia,
incontinent, and mute, with out family or
friends, who spend his day in apparent
discomfort. This man develop
pneumococcal pneumonia
A- healthy , 30 years old mother of two
children who develop pneumococal
pneumonia.
 Why we need EBM
Our daily need for valid information about Dx, Rx, prognosis,
and prevention( up to 5 times per-in pt, and twice for every 3
pts).
Expand knowledge
Need to be updated
Shortage of time for general reading and study.
medical textbooks are old and not always based on evidence
The disparity betw. Our diagnostic skills and clinical judgment,
w increase, and our up-to-date knowledge and clinical
performance which decline.
CME?
Experienced physicians differ
Patho- physiological intuition not work all
the time
>55 bn $/year spend on research
Gap between research and
implementation
Validity of the research?
 Steps for EBM
ASK for the required information
Acquire (find) the information
Appraise the relevance, quality and
importance of the information
Apply the information in your practice or
Pts.
Formulating questions
 Types of questions
Background questions: related to
anatomy, physiology, biochemistry,
pathology, pharmacology

Forward questions: interpretation of

specific diagnostic test, risk and benefit of
a particular treatment or a given Pt
prognosis.
 Framing the question
Dissecting the question into its component
parts to facilitate finding the best evidence
is a fundamental EBM skills
 Determining Q type
Therapy: the effect of different therapy
Harm: the effect of potentially harmful
agents.
Diagnosis: establishing the power of an
intervention to differentiate between those
with or e/o a target condition or disease
Prognosis: estimating the future course of
a patient’s disease.
P (patients)
I (intervention)
C ( comparison)
O (outcome)
 Clinical scenario
A 55-year old white women presents with
type 2 DM & hypertension. Her glycemic
control is excellent on metformin and she
has no history of complications. To
manage her hypertension, she takes a
small daily dose of a thiazide diuretic.
Over a 6 mo period, her BP hovers around
a value of 155/88 mmHg.
Patients: hypertensive type 2 diabetic pt
e/o diabetic complication
Intervention: any antihypertensive
medication aiming at a target SBP< 140
mmHg
Comparison: target systolic BP< 150
mmHg
Outcome: stroke, MI, CV death, total
mortality
 Clinical scenario
A father brought in his 2 year old boy because of
a “cold” and also concern about his hearing and
speech development. He thought the boy
sometimes heard well and other days appeared
deaf. Clinical Ex showed dull tympanic
membranes with retraction on the left. I
wondered how accurate the clinic’s
microtympanometer was for the Dx of OM with
effusion and Eustachian tube dysfunction &
formulated the Question.
what is the accuracy of
microtympanometry for the diagnosis of
hearing loss from a middle ear effusion in
young children?
 Search the evidence
(tympanomet* OR impedance) AND (otitis
media OR middle ear) AND audiomet*
(MEDLINE)
Abdul-Rahman, is a moderately obese 56
years-old man with type 2 DM, smokers,
with no DM complication, his blood sugar
are well controlled on metformin but his
BP has been mildly elevated, he is not
keen to consume additional medication,
and like to see the evidence that lowering
BP with drugs does more good than harm
for people in his case
In a 56- year old man with type 2 DM and
untreated hpt, does tight BP control
reduce subsequent morbidity and
mortality.
Hessa is a 71 years old widow with no important
health problem until she awake one morning
with Rt arm clumsiness. Ex. BP 154/84, you
detect Lt carotid bruit, CV and neurological ex
was normal. Your Dx transient ischemic attack
(TIA) and you prescribe aspirin, you have
recently heard about the benefit of carotid
endarterctomy, for high grade carotid stenosis,
and you would order quick and safe carotid US,
but colleague told you of a similar pt who had a
positive carotid US but negative angiogram, and
wondering how good US in detecting treatable
carotid lesion
In a 71 year-old women with a recent TIA,
is carotid US a trustworthy intermediate
step to angiography in diagnosing
surgically remediable carotid stenosis?
Nouf, a 46 years old women, has
ulcerative colitis ( UC), with extensive
involvement of colon. She is loath to have
surgery but concern about the risk of
cancer, and like to find out what the risk
might be.
In a 46 year old women with extensive
UC, what is the risk for developing bowel
cancer?
“Ulcerative colitis” AND neoplasm AND
cohort studies
A 29 years old man presents with
recurrent furunculosis for past 10 months;
the episodes have been treated with
drainage & several courses of antibiotics
but keep recurring. He ask if recurrence
can be prevented.
P: patients with recurrent furunculosis
I: prophylactic antibiotics
C: no treatment
O: reduction in recurrence of furunculosis