E-Da Hospital / I-Shou University Evidence-Based Medicine

Procedure in EBM Step 1: Step 1: Formulating the management question to be answered (PICO) Step 2: evidence to answer the question Step 2: Searching the literature and on-line databases for evidence to answer the question Step 3: Step 3: Appraising the evidence Step 4: Step 4: Integrating this appraisal with knowledge about the unique aspects of the patient (including preferences) Step 5: Evaluating our effectiveness and efficiency in executing steps and seek ways to improve them

1. Clinical scenario:

2. Question by PICO: P:P: An eighty years old male with DM foot. I :I : Diet control of DM for 30 years. C:C: OHA control; insulin control O:O: Blood sugar levels, complications rate of DM. Q:Q: Is [diet control] more effective than [OHA or insulin] in optimizing [blood sugar levels] and minimizing [complications rate in DM] patients?

3. Search strategy: Via PubMed: P:P: [80 years old OR male OR DM foot] AND I:I: [Diet control OR 30 years] AND C:C: [Oral hypoglycemic agents OR insulin] AND O:O: [Blood sugar control OR complication rate of DM]

4. Search outcome: ( ) papers found of which ( ) were found to be relevant. ( ) papers were discarded as either irrelevant or of insufficient quality for inclusion.

5. Citations: 1.Mathew V., Frye RL., Lennon R., Barsness GW., Holmes DR Jr. Comparison of survival after successful percutaneous coronary intervention of patients with diabetes mellitus receiving insulin versus those receiving only diet and/or oral hypoglycemic agents. American Journal of Cardiology. 93(4): , 2004 Feb 15.Mathew VFrye RLLennon RBarsness GWHolmes DR Jr 2.Nicholson AS., Sklar M., Barnard ND., Gore S., Sullivan R., Browning S. Toward improved management of NIDDM: A randomized, controlled, pilot intervention using a low-fat, vegetarian diet. Preventive Medicine. 29(2):87-91, 1999 Aug.Nicholson ASSklar MBarnard NDGore SSullivan R Browning S 3.Gutierrez M., Akhavan M., Jovanovic L., Peterson CM. Utility of a short-term 25% carbohydrate diet on improving glycemic control in type 2 diabetes mellitus. Journal of the American College of Nutrition. 17(6): , 1998 Dec.Gutierrez MAkhavan MJovanovic LPeterson CM

6. Evidence appraisal: Citation 1:Citation 1: –Study design: 1104 DM patients divided into those treated with insulin (418 patients; median follow-up 35.5 months) vs those treated with either an oral agent or diet alone (686 patients; median follow-up 27.9 months). –Study result: After adjusting for differences in baseline characteristics, insulin treatment did not adversely effect survival (odds ratio 1.10, 95% confidence intervals 0.77 to 1.58).

6. Evidence appraisal: Citation 1:Citation 1: –Validity: Level of evidence: ( ), randomization ( ), controlled ( ) Objectivity: n = ( ), blinding ( ) Follow-up: ( ) –Importance: Relative risk / Odd ratio: Absolute risk reduction: Number needed to treat: –Applicability: Patient similarity: Intervention feasibility: Patient’s preferences:

6. Evidence appraisal: Citation 2:Citation 2: –Study design: 1104 DM patients divided into those treated with insulin (418 patients; median follow-up 35.5 months) vs those treated with either an oral agent or diet alone (686 patients; median follow-up 27.9 months). –Study result: After adjusting for differences in baseline characteristics, insulin treatment did not adversely effect survival (odds ratio 1.10, 95% confidence intervals 0.77 to 1.58).

6. Evidence appraisal: Citation 2:Citation 2: –Validity: Level of evidence: ( ), randomization ( ), controlled ( ) Objectivity: n = ( ), blinding ( ) Follow-up: ( ) –Importance: Relative risk / Odd ratio: Absolute risk reduction: Number needed to treat: –Applicability: Patient similarity: Intervention feasibility: Patient’s preferences:

6. Evidence appraisal: Citation 3:Citation 3: –Study design: 1104 DM patients divided into those treated with insulin (418 patients; median follow-up 35.5 months) vs those treated with either an oral agent or diet alone (686 patients; median follow-up 27.9 months). –Study result: After adjusting for differences in baseline characteristics, insulin treatment did not adversely effect survival (odds ratio 1.10, 95% confidence intervals 0.77 to 1.58).

6. Evidence appraisal: Citation 3:Citation 3: –Validity: Level of evidence: ( ), randomization ( ), controlled ( ) Objectivity: n = ( ), blinding ( ) Follow-up: ( ) –Importance: Relative risk / Odd ratio: Absolute risk reduction: Number needed to treat: –Applicability: Patient similarity: Intervention feasibility: Patient’s preferences:

7. Conclusion: Although these papers provide evidence for the benefits of diet control for NIDDM patients, there is no direct evidence to support it in substituting the role of OHA or insulin in blood sugar control and complications prevention.

8. Plain-language explanation: 膳食療法的確有助於控制糖尿病，但無 證據顯示可以完全代替口服降血糖藥物 或胰島素的功效

EBM worksheet EBM worksheet 1.Clinical scenario 2.Question by PICO 3.Search strategy 4.Search outcome 5.References 6.Evidence appraisal 7.Conclusion 8.Plain-language explanation

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