Lec.1 EBM Dr Ahmed Yehia

1. Evidence- based
medicine (EBM)
‫على‬ ‫المبني‬ ‫الطب‬
‫الدليل‬
Ahmed Yehia Ismaeel
Lecturer, Immunolgy
BSRU President

7. We always dispute
due to absence of
rules.

8. Already , they are present , BUT
we don’t use them.

10. ‫أول‬
‫الرسالة‬
‫الربانية‬
ْ
ْ‫أ‬َ‫ر‬ْ‫ق‬‫ا‬
ْ
ِ‫ب‬َ‫ْر‬ِ‫م‬ْ‫س‬‫ا‬ِ‫ب‬
ْ‫ي‬ِ‫ذ‬َّ‫ل‬‫ْا‬َ‫ك‬
َْ‫ق‬َ‫ل‬َ‫خ‬
(
1
)
ْ
َ‫س‬‫ن‬ِْ
‫ْاْل‬َ‫ق‬َ‫ل‬َ‫خ‬
ْْ‫ن‬ِ‫ْم‬َ‫ان‬
ْ
‫ق‬َ‫ل‬َ‫ع‬
(
2
)
ْ
ْ‫أ‬َ‫ر‬ْ‫ق‬‫ا‬
ْ
‫ب‬َ‫ر‬َ‫و‬
َْ‫ك‬
ْ
‫م‬َ‫ر‬ْ‫ك‬َ ْ
‫اْل‬
(
3
)
ْ‫ي‬ِ‫ذ‬َّ‫ل‬‫ا‬
ْ
َّ‫ل‬َ‫ع‬
ْ
َ‫م‬
ِْ‫م‬َ‫ل‬َ‫ق‬ْ‫ل‬‫ا‬ِ‫ب‬
(
4
)
ْ
َ‫م‬َّ‫ل‬َ‫ع‬
‫ن‬ِْ
‫اْل‬
ْ‫ا‬َ‫م‬َْ‫ان‬َ‫س‬
ْْ‫م‬َ‫ل‬ْ‫ع‬َ‫ي‬ْْ‫م‬َ‫ل‬
(
5
)

11. Is EBM mandatory?
The evidence is the judge in all our life issues.

12. ‫من‬
‫فضلك‬
‫يا‬
‫دكتور‬
‫تقيس‬
‫ضغط‬
‫المريض‬
.

13. Is EBM mandatory?
Glasziou et al. 'a 21st century
clinician who cannot critically
read a study is as unprepared as
one who cannot take a blood
pressure or examine the
cardiovascular system’.
Such illiteracy is common
& clinicians thus foster
unrealistic expectations
about medicine.

14. ‫كيف‬
‫تصنع‬
‫القرار‬
‫في‬
‫ممارساتك‬
‫الطبية‬
‫؟‬
Decision making

15. EBM
Practice
steps

16. EBM
Practice
steps

17. •In the practice of EBM,
it is the physician’s
duty to find the best
and most current
information and apply
it judiciously for the
benefit of the patient.

18. Research
Research
Research
•Trial not theory.
•Many drugs established by
research have unknown
mechanism of action.
•B-blockers

19. EBM
Practice
steps

20. Evidence-based health care?
= best evidence
How to know the best?
20

21. ‫في‬ ‫خبير‬ ‫أنا‬ ‫و‬ ‫رأيي‬ ‫ده‬ ‫دليل؟‬
‫تتولد‬ ‫ما‬ ‫قبل‬ ‫من‬ ‫ده‬ ‫المجال‬
. ‫ده‬ ‫العالج‬ ‫هل‬
‫دليل؟‬ ‫على‬ ‫مبني‬

22. ‫طبعا‬ ‫تصح‬
.
‫الصالة‬ ‫تصح‬ ‫هل‬
‫وضوء؟‬ ‫بغير‬

23. ‫سنين‬ ‫من‬ ‫أنا‬ ‫ابني‬ ‫يا‬
‫باصلي‬
‫من‬
‫أكبر‬ ‫وده‬ ‫ونفعت‬ ‫وضوء‬ ‫غير‬
‫دليل‬
..
‫ده‬ ‫الكالم‬ ‫هل‬
‫دليل؟‬ ‫على‬ ‫مبني‬

24. 24

26. European Academy of
Allergy &
Clinical Immunology's
(EAACI) guideline on
anaphylaxis: 2021
Update
•The EAACI TF was drawn from 9
countries & included allergists
(specialist & subspecialists),
paediatricians, primary care,
immunologists, emergency
physicians, anaesthetists,
dieticians, nurses, psychologist,
education & patient organization
representatives. Methodologists
took the lead in undertaking the
SR, while clinical academics took
the lead in formulating
recommendations for clinical
care.

28. Best
available
evidence

29. If no good quality evidence
available
•Use the best available
evidence.
•This is a knowledge gap.
•Conduct research to create
evidence.

30. ‫واتس‬ ‫رسالة‬
‫هامة‬
!!!
•
‫بكين‬ ‫مستشفى‬ ‫عام‬ ‫مدير‬ ‫هورين‬ ‫تشن‬ ‫البروفيسور‬ ‫يقول‬
..
‫أن‬
*
‫ليمون‬
‫دافئة‬ ‫ة‬
‫حياتك‬ ‫طول‬ ‫تفيدك‬
.*
•
*
‫ا‬‫ل‬‫أو‬
:*
‫السرطانية‬ ‫الخاليا‬ ‫يقتل‬ ‫ان‬ ‫الحار‬ ‫الليمون‬ ‫يستطيع‬
!
•
*
‫علي‬ ‫الحار‬ ‫الماء‬ ‫أسكب‬ ‫ثم‬ ‫كوب‬ ‫في‬ ‫وضعها‬ ‫قطع‬ ‫ثالثة‬ ‫إلى‬ ‫الليمونة‬ ‫اقطع‬
،‫ها‬
‫فستصبح‬
(
‫قلوية‬ ‫مياه‬
)
‫شخص‬ ‫أي‬ ‫وستفيد‬ ‫ا‬‫ا‬‫يومي‬ ‫أشربوها‬
*..
•
*
‫الس‬ ‫لخاليا‬ ‫مضادة‬ ‫المذاق‬ ‫ه‬َّ‫ر‬ُ‫م‬‫و‬ ‫حلوة‬ ‫مادة‬ ‫إطالق‬ ‫يستطيع‬ ‫الحار‬ ‫الليمون‬
، ‫رطان‬
‫الطبي‬ ‫المجال‬ ‫في‬ ‫السرطان‬ ‫لعالج‬ ‫بحث‬ ‫آخر‬ ‫وهذا‬
*.
•
‫فيتامين‬ ‫مجرد‬ ‫هاوثورن‬ ‫ليمونادة‬
(
‫ج‬
)
‫للحصول‬ ‫طهوها‬ ‫يجب‬ ‫الطماطم‬ ‫أن‬ ‫كما‬
‫على‬
‫الليكوبين‬
..
•
*
‫الحار‬ ‫الليمون‬ ‫لعصير‬
*
‫السرطانية‬ ‫واألكياس‬ ‫األورام‬ ‫على‬ ‫تأثير‬
..
•
‫السرطانات‬ ‫انواع‬ ‫لجميع‬ ‫ا‬‫ا‬‫عالج‬ ‫أظهر‬ ‫كما‬
.
•
‫عل‬ ‫يؤثر‬ ‫ولن‬ ‫الخبيثة‬ ‫الخاليا‬ ‫بتدمير‬ ‫سيقوم‬ ‫المستخلص‬ ‫هذا‬ ‫ب‬ ‫العالج‬
‫الخاليا‬ ‫ى‬
‫السليمة‬
..
•
*
‫ا‬‫ا‬‫ثاني‬
:*
‫ينظم‬ ‫الليمون‬ ‫عصير‬
‫إرتفاع‬
‫الشر‬ ‫ضيق‬ ‫من‬ ‫ويحمي‬ ‫الدم‬ ‫ضغط‬
، ‫ايين‬
‫الدم‬ ‫تجلط‬ ‫ويقلل‬ ، ‫الدموية‬ ‫الدورة‬ ‫ويضبط‬
.
•
*
‫نصائح‬
*:
•
‫ما‬ ‫شخص‬ ‫يساعد‬ ‫فإنه‬ ‫الرسالة‬ ‫هذه‬ ‫ينشر‬ ‫شخص‬ ‫أي‬
...
•
*
‫األجر‬ ‫ولكم‬ ‫نشرها‬ ‫في‬ ‫تساعدوا‬ ‫أن‬ ‫أتمنى‬
.*

32. Apples,
pears linked
to reduced
stroke risk
•While studies have consistently
shown that a high consumption of
fruit and vegetables overall is
associated with a lower stroke risk,
the researchers note that few
studies have examined the
association between stroke risk
and fruits and vegetables grouped
according to color.
http://www.medscape.com/viewarticle/791032
Susan Jeffrey, September 16, 2011

33. • The color of the primary edible
portion of fruits and vegetables
reflects the presence or absence of
particular pigmented bioactive
compounds, such as carotenoids,
anthocyanidins, and flavonoids. High
consumption of which fruits and
vegetables in particular contribute the
most to reduction in stroke risk isn't
known.

34. •The researchers used data from
the Monitoring Project on Risk Factors and
Chronic Diseases in the Netherlands )
MORGEN) study, a population-based cohort
study of 20 069 men and women aged 20 to
65 years free of cardiovascular disease at
baseline.
•Information on fruit and vegetable intake was
taken from a validated, 178-item food
frequency questionnaire that included juices
and sauces.

35. Fruits and vegetables were
classified into four color groups
according to the edible portion:
1. green included such items as
broccoli, Brussels sprouts, and
kiwi fruit;
2. orange/yellow included citrus
fruits, carrots, and cantaloupe;
3. red/purple encompassed foods
such as cherries, grapes, red
cabbage, and tomatoes; and
4. white included the allium
family of garlic and onion, hard
fruits like apples and pears, as
well as bananas, cauliflower,
and cucumber.

36. Results
•High intake of fruits and vegetables with a
white flesh—mainly apples and pears in this
research—and reduced risk of stroke on the
order of 50% .
•Each 25-g/day increase in white fruit and
vegetable consumption was associated with
a 9% lower risk of stroke (HR 0.91, 95% CI
0.85-0.97).

37. And another study
December 18, 2013
http://www.medscape.com/viewarticle/817972
According to the new analysis by British researchers, if individuals ate just one extra apple a day,
approximately 8500 deaths from vascular disease could be prevented in the UK.
The reduction in vascular deaths by adding an apple to the diet is on par with the reduction that would be
observed if all UK individuals over 50 years of age were prescribed statin therapy. In that scenario, 9400 deaths
from vascular disease could be prevented if these adults were started on simvastatin 40 mg.

38. • Now, we're not trying to
say that people should be
swapping their statins for
apples; that's not where
we're going. However, if
they want to add an
apple to that as part of
disease prevention, then
by all means do so,
because you'll be further
along in reducing your
risk of fatal heart attacks
and strokes."

39. • For statin therapy, offering the
treatment to an extra 17 million
individuals and assuming 70%
compliance would prevent 9400 vascular
deaths each year. Assuming 70%
compliance with the apple, even though
"apples are of course both delicious and
nutritious,", the estimated reduction in
vascular deaths would be 8500. They
add that prescribing statins to all those
eligible would lead to 1200 cases of
myopathy, 200 cases of rhabdomyolysis,
and 12 300 new diagnoses of diabetes
mellitus.

40. And a third:Will an Apple a Day
Keep Pancreatic Cancer Away?
• “Apoptosis," is a Greek expression meaning
"leaves that fall from trees." Why?
• Chemicals :flavonoids and glycans -- yellow in
color, and these induce the leaves to apoptose.
• Control of proliferation and cell cycle.
• This is a very beautiful study from La Vecchia and
colleagues suggesting that a diet rich in
flavonoids and glycans can reduce the chances
of developing pancreatic cancer by more than
25%.
http://www.medscape.com/viewarticle/770268
David J. Kerr, MD ,September 07, 2012

41. An Apple a
Day Will
Keep the
Doctor Away

42. Evidence is that laparoscopic
cholecystectomy has better
outcomes than open surgery.

43. JIA
guidelines

44. MAJOR
COMPONENT
S of EBM
PATIENT
PHYSICIAN
Evidence
Question
or
Problem

45. BUT… Past knowledge and practice
might be outdated or inadequate
Graduate Medical School Practiced Physician

46. Case
• A 70-year-old female with a history of
hyperlipidemia & a new diagnosis of hypertension,
looking at hypertension treatment options. You
found a good randomized controlled trial looking
at medications to control hypertension, but the
study's inclusion criteria were a population of 18
to 65-year-olds.
• Should you ignore the results as the specific
patient does not meet the study demographics?
• Should you ignore the age difference between the
specific patient and study population? This is
where the clinical judgment helps bridge the gap
between the relevant scientific evidence and the
specific patient being treated.

47. • Most clinical studies have specific inclusion &
exclusion criteria, as well as the specific
population studied. More often than not, the
patient being treated by the clinician will have
one or more substantial differences from the
population in the study. The medical provider
must then use their clinical judgment to
determine how the variations between the
patient & the study population are important
or not and how they affect applying the study
results to the specific patient.

48. A 40-year-old man
was diagnosed with
rheumatoid
arthritis. How to
treat?

49. ‫يا‬ ‫العالج‬ ‫إيه‬
‫دكتور؟‬
!
!!!!!
How to search
literature?

50. Guidelines
‫و‬ ‫كيماوي‬ ‫أنه‬ ‫سمعت‬
‫كمان‬
‫بيسقط‬
‫الشعر‬
‫ليه؟؟‬
!!

51. Guidelines
‫ما‬ ‫انت‬ ‫و‬ ‫أنا‬ ‫ما‬ ‫طب‬
‫عندناش‬
‫شعر‬
‫لو‬ ‫و‬

52. Guidelines
‫هاشرح‬
‫لك‬
‫لو‬ ‫و‬
Education about current alternatives
and risks is often needed… for both
the Patient and the Doctor!

53. ‫الشفوي‬ ‫لجنة‬ ‫في‬
‫بتعالج‬
‫الروماتويد‬
‫بإيه‬
‫؟‬
Gold &
penicillamine

54. ‫ضع‬
‫الكرة‬
‫في‬
‫ملعبه‬
• Clinicians using EBM must put all of
the information in the context of the
patient's values or preferences.
• The patient's values or preferences
may conflict with some of the
possible options. Even strong
evidence supporting a specific
treatment may not be compatible
with the patient's preferences, and
thus, the clinician may not
recommend the treatment to the
patient. Also, the treatment might
not apply to the specific patient.

55. But… A practice based exclusively on science
& math is effective only if your patients are
robots!
Don’t forget to allow for individual human differences
and personal preferences!

56. The patient’s preferences MUST be considered!
An important rule in Evidence Based Medicine…
It STARTS with the patient and ENDS with the patient.
Patient-centered

57. ‫يعني‬
‫أنا‬
‫ما‬
‫ليش‬
‫قرار‬
‫؟‬
Shared Decision Making

58. PATIENT
PHYSICIAN
INFORMATION
Question
or
Problem
THREE MAJOR
COMPONENTS of EBM

59. PATIENT
Values, Concerns Preferences,
Expectations
Life predicament
PHYSICIAN
Training & Experience
Current Expertise
Continued learning
Demand for proof
INFORMATION
Clinically relevant
Proven by research
Best up-to-date evidence
EBM
THE ADDED DETAILS

60. The basic steps of EBM

62. Never speak or practice without evidence.
•
“
‫و‬
‫أن‬
‫تقولوا‬
‫على‬
‫هللا‬
‫ما‬
‫ل‬
‫تعلمون‬
•
"
َ
‫ل‬ َ‫و‬
ُ‫ف‬ْ‫ق‬َ‫ت‬
‫ا‬َ‫م‬
َ‫ْس‬‫ي‬َ‫ل‬
َ‫ك‬َ‫ل‬
‫ب‬
‫ه‬
‫م‬ْ‫ل‬‫ع‬
ۚ
َّ‫ن‬‫إ‬
َّ‫س‬‫ال‬
َ‫ع‬ْ‫م‬
َ‫ر‬َ‫ص‬َ‫ب‬ْ‫ال‬ َ‫و‬
َ‫د‬‫ا‬َ‫ؤ‬ُ‫ف‬ْ‫ال‬ َ‫و‬
‫ل‬ُ‫ك‬
َ‫ك‬‫ئ‬ََٰ‫ل‬‫و‬ُ‫أ‬
َ‫ان‬َ‫ك‬
ْ‫ن‬َ‫ع‬
ُ‫ه‬
‫ا‬
‫ول‬ُ‫ئ‬ْ‫س‬َ‫م‬
(36)"
•
ْ‫ل‬ُ‫ق‬
‫وا‬ُ‫ت‬‫ا‬َ‫ه‬
ْ‫م‬ُ‫ك‬َ‫ن‬‫ا‬َ‫ه‬ ْ‫ر‬ُ‫ب‬
‫ن‬‫إ‬
ْ‫م‬ُ‫ت‬‫ن‬ُ‫ك‬
‫ق‬‫اد‬َ‫ص‬
َ‫ين‬
‫فن‬
‫الهبد‬

64. (
ْ‫د‬َ‫ق‬َ‫ل‬
ْ‫ق‬َ‫ل‬َ‫خ‬
‫َا‬‫ن‬
‫اإلنسان‬
‫في‬
‫ن‬َ‫س‬ْ‫ح‬َ‫أ‬
َ‫ت‬
‫يم‬‫و‬ْ‫ق‬
)

65. ‫متأكد‬ ‫مش‬
.
‫عارف‬ ‫مش‬
.
!!!!!!!!!!

66. What shall I benefit from research?!

67. ‫على‬
‫المستوى‬
‫الشخصي‬

68. Benefits of practicing EBM
1. Improves your efficacy.
2. Decreases the areas of disputes.
3. Protects you from punishment.
4. Improves your CV & qualification.
5. Decision-making.

69. ‫على‬
‫مستوى‬
‫الجامعة‬

70. ‫من‬
‫أجل‬
‫بلدي‬

71. ‫أفضل‬
‫عشر‬
‫جامعات‬
‫في‬
‫العالم‬
‫هارفارد‬ ‫جامعة‬
–
‫المتحدة‬ ‫الوليات‬
.
‫ستانفورد‬ ‫جامعة‬
–
‫المتحدة‬ ‫الوليات‬
.
‫للتكنولوجيا‬ ‫ماساتشوستس‬ ‫معهد‬
–
‫المتحدة‬ ‫الوليات‬
.
‫كاليفورنيا‬ ‫جامعة‬
–
‫المتحدة‬ ‫الوليات‬
.
‫واشنطن‬ ‫جامعة‬
–
‫المتحدة‬ ‫الوليات‬
.
‫ميشيغان‬ ‫جامعة‬
–
‫المتحدة‬ ‫الوليات‬
.
‫أوكسفورد‬ ‫جامعة‬
–
‫بريطانيا‬
.
‫كولومبيا‬ ‫جامعة‬
–
‫المتحدة‬ ‫الوليات‬
.
‫كورنيل‬ ‫جامعة‬
–
‫المتحدة‬ ‫الوليات‬
.
‫بنسيلفانيا‬ ‫جامعة‬
–
‫الوليات‬
‫المتحدة‬
.

72. ‫عشر‬ ‫أفضل‬
‫غير‬ ‫جامعات‬
‫العالم‬ ‫في‬ ‫أمريكية‬
‫أكسفورد‬ ‫جامعة‬
–
‫بريطانيا‬
(
‫ا‬‫ا‬‫ي‬‫عالم‬ ‫السابعة‬ ‫المرتبة‬
.)
‫كامبريدج‬ ‫جامعة‬
–
‫بريطانيا‬
(
‫المرتبة‬
11
‫ا‬‫ا‬‫ي‬‫عالم‬
.)
‫تورنتو‬ ‫جامعة‬
–
‫كندا‬
(
‫المرتبة‬
18
‫ا‬‫ا‬‫ي‬‫عالم‬
.)
‫لندن‬ ‫جامعة‬
–
‫بريطانيا‬
(
‫المرتبة‬
21
‫ا‬‫ا‬‫ي‬‫عالم‬
.)
‫البريطانية‬ ‫كولومبيا‬ ‫جامعة‬
–
‫كندا‬
(
‫المرتبة‬
29
‫ا‬‫ا‬‫ي‬‫عالم‬
.)
‫للتكنولوجيا‬ ‫زيورخ‬ ‫معهد‬
–
‫سويسرا‬
(
‫المرتبة‬
32
‫ا‬‫ا‬‫ي‬‫عالم‬
.)
‫هوا‬ ‫تسينغ‬ ‫جامعة‬
–
‫الصين‬
(
‫المرتبة‬
40
‫ا‬‫ا‬‫ي‬‫عالم‬
.)
‫أدنبرة‬ ‫جامعة‬
–
‫بريطانيا‬
(
‫المرتبة‬
43
‫ا‬‫ا‬‫ي‬‫عالم‬
.)
‫كونغ‬ ‫هونغ‬ ‫جامعة‬
–
‫كونغ‬ ‫هونغ‬
(
‫المرتبة‬
47
‫ا‬‫ا‬‫ي‬‫عالم‬
.)
‫ملبورن‬ ‫جامعة‬
–
‫أستراليا‬
(
‫المرتبة‬
49
‫ا‬‫ا‬‫ي‬‫عالم‬
)

74. ‫أفريقيا‬

75. ‫عربي‬
‫ا‬

78. Middle
East

79. To become producer not consumer.

80. For the sake of the humanity

81. The problem is in our
utilization of the available
limited resources.

82. ‫و‬ ‫لإلحباط‬ ‫ال‬
‫المحبطين‬

84. ‫المثبطين‬ ‫و‬ ‫لإلحباط‬ ‫ال‬
.

85. ‫قال‬
‫رسول‬
‫هللا‬
‫صلى‬
‫هللا‬
‫عليه‬
‫وسلم‬
" :
‫إذا‬
‫قال‬
َّ‫الر‬
‫ل‬ُ‫ج‬
َ‫ك‬َ‫ل‬َ‫ه‬
‫الناس‬
،
‫فهو‬
ْ‫ه‬َ‫أ‬
‫م‬ُ‫ه‬ُ‫ك‬َ‫ل‬
".

87. Then ,
the first
step is to
set your
goal.

91. ‫يوميات‬
‫عادي‬
‫و‬
‫عادية‬

92. ‫شخص‬
‫غير‬
‫عادي‬

93. Then , the first step is to set your goal.

96. «
‫بأنفسه‬ ‫ما‬ ‫يغيروا‬ ‫حتى‬ ‫بقوم‬ ‫ما‬ ‫يغير‬ ‫ال‬ ‫هللا‬ ‫إن‬
‫م‬
»
RESEARCH
SCIENTIFIC

97. The 2nd step , we invite
you to join us.

98. You are all welcome.

99. We shall work together.

100. To achieve integrity.

102. The 3rd , 4th , 5th …., 1000th Steps.

103. That’s too much. I am a student.

104. A student…..

105. A student in the faculty of medicine

106. ‫ما‬
‫تنساش‬
‫فرحتك‬
‫و‬
‫فرحة‬
‫أهلك‬
‫لما‬
‫دخلت‬
‫كلية‬
‫الطب‬
!!

107. Medicine
doctor

111. Appraise

113. EBM starts with the
clinical question &
returns to the clinical
question.

114. ‫هللا‬ ‫جزاكم‬
‫خيرا‬
.
‫جملة‬ ‫بأول‬ ‫صدرا‬ ‫تكن‬ ‫لم‬ ‫إن‬
‫إسهاب‬ ‫في‬ ‫للمجد‬ ‫ا‬‫ال‬‫فاع‬ ‫أو‬
..
‫ا‬‫ب‬‫غائ‬ ‫ا‬‫ا‬‫ضمير‬ ‫تبقى‬ ‫أن‬ ‫إياك‬
‫ا‬
‫اإلعراب‬ ‫من‬ ‫له‬ ‫محل‬ ‫ل‬ ‫أو‬

115. Not sure

116. 122
Confidence Interval
• To p or not to p

117. 123
Grading of evidence
• Ia: Systematic review or meta-analysis of randomized controlled
trials
• Ib: at least one randomized controlled trial
• IIa: at least one well-designed controlled study without
randomization
• IIb: at least one well-designed quasi-experimental study, such as
a cohort study
• III: well-designed non-experimental descriptive studies, such as
comparative studies, correlation studies, case–control studies
and case series
• IV: expert committee reports, opinions and/or clinical
experience of respected authorities

118. 124
Grading of recommendations
• A: based on hierarchy I evidence
• B: based on hierarchy II evidence or extrapolated from hierarchy I
evidence
• C: based on hierarchy III evidence or extrapolated from hierarchy I or
II evidence
• D: directly based on hierarchy IV evidence or extrapolated from
hierarchy I, II or III evidence