1 Introduction to Evidence- Based Medicine: question formulation Dr Kamal R. Mahtani BSc PhD MBBS PGDip MRCGP GP and Clinical Lecturer Centre for Evidence Based Medicine University of Oxford October 2014
3 Outline of the EBM Thread Today 9 to 9.45am Why we need EBM Question formulation Assignment 10 to 11 am Critical appraisal of RCTS 11 to 12 am Systematic Reviews pm Searching the evidence 4pm to 5pm Searching session (optional) (Cairns library/ private study) Tues pm Presentations (see back of workbook)
4 Assignment Assigned to work in pairs 7 minute presentation 3 minutes for questions
5 Assignment (criteria) Turning up Clinical Question using PICO Search strategy Appraisal Interpretation of findings Clear recommendation Overall Impression
6 The Question Mr. X is a 58 year old obese gentleman suffering from non-insulin-dependent diabetes mellitus. We want to know whether the drug metformin could be used to improve his condition, as measured by lowering his glycosylated haemoglobin. P I C O Obese adults suffering from NIDDM Metformin Placebo Change in glycosylated haemoglobin
7 The Search We Searched PubMed for the following terms Non-insulin-dependent diabetes mellitus (MeSH) Metformin Glycosylated haemoglobin Placebo Obese Out of the 8 trials that appeared through the search, we selected the DeFronzo 1995 trial as it s abstract suggested it was the most relevant to our question.
8 The Study appraisal Study title Efficacy of metformin in patients with non-insulin-dependent diabetes mellitus. Critical appraisal Randomisation: the paper did not disclose the method of randomisation, therefore we cannot eliminate the possibility of the introduction of bias through inappropriate methods of randomisation. However, the baseline demographics appeared satisfactory. Ascertainment: there was a follow up of 78% in the metformin group and 72% in the placebo group, which could be better. Measurements: our chosen outcome of glycosylated haemoglobin is an objective measurement, and not operator dependent, therefore is less open to bias from the technicians involved. Blinding: full double blinding was carried out throughout the trial, again reducing possibilities for the introduction of biases.
9 The Results (interpretation of findings) The measurements for mean glycosylated haemoglobin (±SE) in the two groups were as follows. In the metformin group: 7.1% (±0.1%) In the placebo group 8.6% (±0.2%) There was a mean absolute reduction in glycosylated haemoglobin of 1.5% in the metformin group, bringing the patients closer to the ideal of under 7%. However, there were more side effects in the metformin group (14) than the placebo group (2). The side effects were digestive symptoms, primarily diarrhoea.
10 The Implications Based on these results, we would feel happy to recommend that Mr. X be treated with metformin for his non-insulindependent diabetes mellitus. We would also warn him of the risk of adverse digestive side effects. Given time, we would like to look at more papers to see how metformin compares to other drugs for treatment of NIDDM, such as glicazide and insulin.
11 Patient concern Improved patient outcomes Best research evidence Clinical expertise
12 EBM can (amongst other things!) Help you make clinical decisions Share decision making with patients Provide better diagnostic reasoning Understanding benefits versus harms Allow you to practice more safely
13 Practicing EBM the 4 A s Step 4 Step 3 Step 2 Step 1 Ask a clinical question Acquire the best evidence Appraise the evidence Apply the evidence
14 The EBM cart in the old days
17 Practicing EBM the 4 A s Step 4 Step 3 Step 2 Step 1 Ask a clinical question Acquire the best evidence Appraise the evidence Apply the evidence
18 Types of questions Specific clinical decisions Primary/pre assessed studies Patient centred Diagnosis, prognosis, management of disease More general Whole condition, symptoms, signs Pathophysiology Textbooks/online
19 Question formulation using PICO WB p4 Element Tips Example Starting with your patient ask How would I describe a group of patients similar to mine? Balance precision with brevity. Patient or Problem Intervention Comparison (Intervention) Outcomes Ask Which main intervention am I considering? Be Specific Ask What is the main alternative to compare with the intervention? Be specific Ask What can I hope to accomplish? or What could this exposure really affect? Be specific In patients with heart failure from dilated cardiomyopathy who are in sinus rhythm would adding anticoagulat-ion with warfarin to standard heart failure therapy, when compared with standard therapy alone, lead to lower mortality or morbidity from thromboembolism."
20 Types of question 1. How common is the problem Prevalence 2. Is early detection worthwhile Screening 3. Is the diagnostic test accurate Diagnosis 4. What will happen if we do nothing Prognosis 5. Does this intervention help Treatment 6. What are the harms of an intervention Harms
21 Clinical scenario Mrs Whish, is a 28 y solicitor. She comes to see you today as she is frustrated by the symptoms of his irritable bowel syndrome. She feels that they have got worse and despite trying numerous things that you have suggested nothing has helped. She read an article in The Daily Mail suggesting that probiotic drinks help and wonders what you think?
22 Framing questions: using PICO Patient/ Population Broad Adults with IBS Specific Gender? Age? How long have they had IBS? Intervention Probiotics Type? Tablet? Drink? Comparison No probiotics Placebo? Standard therapy? Outcome Improve symptoms Which ones? All?
23 Scenario 2 CHILDHOOD SEIZURES Childhood seizures are common and frightening for the parents, and the decision to initiate treatment is a difficult one. What is the risk of further recurrences following a single seizure of unknown cause? WB p7
24 Scenario 3 VACCINATION AND NEEDLE LENGTH You are the practice nurse and one of your colleagues tells you it is better to use a short needle than a long needle when immunising babies for their first ever vaccinations, as it reduces the swelling and decreases the parents anxiety about further vaccinations. You wonder if your colleague is correct? WB p8
25 Scenario 4 p9 CHILDREN AND ANTIVIRALS You are the GP and the next patient brings their 3 year old child who is unwell with a fever, the mother wants to know whether she should give the child tamiflu? WB p9
26 Angela is a patient on the general medical ward who recently moved to the area to be closer to her son and his family. She is 72 years old and has a history of congestive heart failure. She was admitted 2 days ago having presenting with non specific chest pain, shortness of breath, an enlarged liver, swollen ankles and has been diagnosed with a Non ST elevation MI. She has been hospitalized twice within the last 6 months for worsening of heart failure. What are your questions? At the present time she says she is pain free and is extremely diligent about taking her medications (lisinopril and aspirin), and wants desperately to stay out of the hospital. She reports being mobile and lives alone with several cats. She also tells you she is a bit hard of hearing, has a slight cough, is a smoker of 20 cigs a day for 40 years. When you examine her: BP is 170/90, her ankles are slightly swollen, her pulse is 80 and irregular, her Hb is 10.5g/dL and her Na is 132. ir WB p5 She is about to be discharged home on her previous medications plus 25mg spironolactone od. She is happy to be going home and asks you if this new medication will help her stay out of hospital?i
27 Patient or Problem Intervention Comparison intervention Outcomes Tips for Buildi ng Describe a group of patients similar to your own What intervention are you considering What is the main alternative to the intervention What do you hope to accomplish with the intervention Exam ple In elderly patients with congestive heart failure does treatment with spirinolactone when compared with standard therapy alone lead to a decrease in hospitalization
28 Practicing EBM the 4 A s Step 4 Step 3 Step 2 Step 1 Ask a clinical question Acquire the best evidence Appraise the evidence Apply the evidence
29 Types of evidence
30 Levels of evidence
31 Patient or Problem Intervention Comparison intervention Outcomes Tips for Buildi ng Describe a group of patients similar to your own What intervention are you considering What is the main alternative to the intervention What do you hope to accomplish with the intervention Exam ple In elderly patients with congestive heart failure does treatment with spirinolactone when compared with standard therapy alone lead to a decrease in hospitalization
33 Apply the evidence We can tell Angela that her new drug could reduce her risk of being rehospitalised by 35% as well as improving some the symptoms of her heart failure
34 Analysis of abstracts 1. What is the question (PICO) of the study? 2. What is the purpose of the study? 3. Which study type would give the highest quality evidence to answer the question? 4. Which is the best study type that is also feasible? 5. What is the study type used? 6. What do the results mean? WB p16
35 Analysis of abstracts 1. What is the question (PICO) of the study? 2. What is the purpose of the study? 3. Which study type would give the highest quality evidence to answer the question? 4. Which is the best study type that is also feasible? 5. What is the study type used? 6. What do the results mean? WB p17
36 PICO exercise Think of clinical question/scenario you have come across. Frame it in a PICO format What type of question is it? Aetiology/cause? Prognosis? Diagnosis? Treatment/intervention How will you answer the question?
37 Practicing EBM the 4 A s Step 4 Step 3 Step 2 Step 1 Ask a clinical question Acquire the best evidence Appraise the evidence Apply the evidence
38 Outline of the EBM Thread Today 9 to 9.45am Why we need EBM Question formulation Assignment 10 to 11 am Critical appraisal of RCTS 11 to 12 am Systematic Reviews pm Searching the evidence 4pm to 5pm Searching session (optional) (Cairns library/ private study) Tues pm Presentations (see back of workbook)
39 Risk of bias assessment of internal validity Critical appraisal Do I believe it?
40 Practicing EBM the 4 A s Step 4 Step 3 Step 2 Step 1 Ask a clinical question Acquire the best evidence Appraise the evidence Apply the evidence
41 External validity Will it change the way I manage this patient?
42 Assignment Assigned to work in pairs 7 minute presentation 3 minutes for questions
43 Assignment (criteria) Turning up Clinical Question using PICO Search strategy Appraisal Interpretation of findings Clear recommendation Overall Impression
44 Does cinnamon reduce fasting blood glucose in Type II diabetics? Emma Thurston and Suzanne Harrogate
45 The Question Miss S. has poorly managed Type II diabetes and asks if taking cinnamon would improve her fasting blood glucose levels. P I C O 57 year old lady with poorly managed Type II diabetes Eating cinnamon in addition to prescribed medication Diabetic medication without cinnamon Fasting blood glucose levels
46 The Search We searched the MEDLINE database: Cinnamon AND diabetes Cinnamon AND Type II diabetes AND fasting blood glucose We selected: Leach MJ, Kumar S. Cinnamon for diabetes mellitus. Cochrane Database of Systematic Reviews 2012, Issue 9 This article systematically reviewed papers investigating whether cinnamon affected diabetic management, using fasting blood glucose as its primary outcome. The paper s recent publication suggests that the latest evidence collected will have been included in their review. The mean age range of participants in trials reviewed included that of Miss S.
47 The Study appraisal Leach MJ, Kumar S. Cinnamon for diabetes mellitus. Cochrane Database of Systematic Reviews 2012, Issue 9 The authors search: 14 search engines were used to find relevant papers, including: The Cochrane Library (issue 12, 2011). MEDLINE (until January 2012). EMBASE (until January 2012). Selection: 2 reporters independently scanned the abstract of every paper retrieved by the search to ensure inclusion criteria were met: Randomised controlled trials Orally administered monopreparations of cinnamon Placebo/ active medication/ no treatment. Type I or II diabetes Potential limitation only papers published in English were selected. Pertinent reports published in other languages may have been missed.
48 RANDOMISATION 10 prospective, parallel-group design, randomised control trials, involving a total of 577 participants with either Type 1 or 2 diabetes were included. 1 of the 10 studies didn t use a placebo control. 6 studies were double-blinded, 2 single-blinded and 2 undefined with respect to blinding. However, the precise blinding protocol was not clearly described in many trials included in the review. ALLOCATION Gender was approximately distributed evenly in most trials. The mean age of participants ranged from years. Bias was assessed independently by two reviewers using a pre-defined criteria (Higgins, 2008). Risk of bias was high or unclear in 8/10 trials, with the remaining 2 assessed as having a moderate risk. Leach MJ, Kumar S., 2012.
49 MAINTENANCE All studies used oral monopreparation of cinnamon in tablet or capsule form. 3 studies were excluded after careful evaluation of the full publication primarily due to failure to meet the diagnostic criteria for Type 1 or 2 diabetes. Where possible, any relevant missing information on the trial was sought from the original author(s) of the article e.g. reasons for drop-outs were inconsistently reported. MEASUREMENT Heterogeneity was assessed by visual inspection of the forest plots and by using a standard Chi 2 test: Cinnamon vs. Placebo; Outcome fasting blood glucose level (mmol/l) Chi 2 =0.97. If one of the primary outcome parameters showed significant differences between the intervention groups subgroup analysis was performed: Cinnamon species Cinnamon dosage Treatment duration Type of diabetes (I or II)
50 The Results (interpretation of findings) There were 8 studies reporting data on fasting blood glucose for 388 participants. These showed significant heterogeneity (Chi 2 =0.82). Visual inspection of the funnel plot and subgroup analysis led the authors to exclude 2 out of these 8 studies as outliers. Analysis of the 6 remaining studies found no statistically significant difference in fasting blood glucose between cinnamon and placebo groups (P=0.55 ; 95%CI to 0.18). Adverse effects were recorded in 4 trials. 3 events in intervention groups: Rash Hives Hypoglycaemic episode 4 events in control groups. Nausea Stomach ache Other frequent illness Overall, there was no significant difference between adverse effects in the intervention and control group.
51 The Implications Based upon this systematic review there is no statistically significant evidence to support a doctor advising a patient like Miss S to take cinnamon in an attempt to lower their fasting blood glucose levels. Miss S. should be warned that if she does take cinnamon there is a small possibility of her experiencing some mild side effects. It would also be worthwhile to suggest she checks she is not allergic to cinnamon before embarking on a treatment programme.
EMA/467911/2014 Summary of the risk management plan (RMP) for Xultophy (insulin degludec / liraglutide) This is a summary of the risk management plan (RMP) for Xultophy, which details the measures to be
New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants
Version History Policy Title Drugs for MS.Drug facts box fingolimod Version 1.0 Author West Midlands Commissioning Support Unit Publication Date Jan 2013 Review Date Supersedes/New (Further fields as required
York Teaching Hospital NHS Foundation Trust Atrial Fibrillation and Anticoagulants A guide to your diagnosis and treatment Information for patients, relatives and carers For more information, please contact:
1 PATIENT INFORMATION HUMULIN R REGULAR INSULIN HUMAN INJECTION, USP (rdna ORIGIN) 100 UNITS PER ML (U-100) WARNINGS Do not share your syringes with other people, even if the needle has been changed. You
Frequently asked questions about whooping cough (pertussis) About whooping cough What is whooping cough? Whooping cough is a highly contagious illness caused by bacteria. It mainly affects the respiratory
1 There is fair (2b) level evidence that living skills training is effective at improving independence in food preparation, money management, personal possessions, and efficacy, in adults with persistent
New Treatments for Stroke Prevention in Atrial Fibrillation John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 Classification Paroxysmal atrial fibrillation (AF) Last < 7
Title of critically appraised topic: Is probiotic use an effective adjuvant therapy to antibiotics in treatment of Clostridium difficile-associated diarrhea? Author: (This copy has been stripped of identifiers)
Great Ormond Street Hospital for Children NHS Foundation Trust: Information for Families Multiple sclerosis disease-modifying drugs second line treatments The following information should be read in conjunction
Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus NICE has developed the Cochrane Quality and Productivity (QP) topics to help the NHS identify practices
FORMULATING THE RESEARCH QUESTION James D. Campbell, PhD Department of Family and Community Medicine University of Missouri Where do questions come from? From patient-centered questions in routine clinical
Positron Emission Tomography - For Patients A physician s written order is required for any PET-CT tests. How should I prepare for my PET-CT? PET-CT is more complicated than most other tests you may be
Pneumonia Guide to Your Recovery www.cpmc.org/learning i learning about your health What are the Causes of Pneumonia? Pneumonia is an inflammation in one or more parts of your lungs. Pneumonia may be caused
Formulating the Review Question & Writing a Protocol Madhukar Pai, MD, PhD Associate Professor Department of Epidemiology & Biostatistics McGill University, Montreal, Canada Email: email@example.com
After your child is immunised What to expect after immunisations This leaflet tells you what reactions might occur after immunisation, and what to do about them. Only use this information as a guide. You
Type 2 diabetes Definition Type 2 diabetes is a lifelong (chronic) disease in which there are high levels of sugar (glucose) in the blood. Type 2 diabetes is the most common form of diabetes. Causes Diabetes
Page 1 of 6 Chemotherapy Side Effects Worksheet Medicines or drugs that destroy cancer cells are called cancer chemotherapy. It is sometimes the first choice for treating many cancers. Chemotherapy differs
Patient s Guide to Antithrombotic Therapy in Atrial Fibrillation A Patient s Guide to Antithrombotic Therapy in Atrial Fibrillation PATIENT EDUCATION GUIDE What is atrial fibrillation? Atrial fibrillation
www.bpac.org.nz keyword: warfarinaspirin FOR THE PREVENTION OF ATRIAL FIBRILLATION RELATED STROKE Key Concepts In atrial fibrillation (AF) warfarin is more effective than aspirin for stroke prevention.
Shared Care Guideline for Prescription and monitoring of Acamprosate Calcium Author(s)/Originator(s): (please state author name and department) Dr Daly - Consultant Psychiatrist, Alcohol Services Dr Donnelly
Anticoagulants for stroke prevention in atrial fibrillation Patient frequently asked questions What is atrial fibrillation?...2 What are dabigatran, rivaroxaban and apixaban and what are they used for?...2
Northern Treatment Advisory Group Rivaroxaban for acute coronary syndromes Lead author: Nancy Kane Regional Drug & Therapeutics Centre (Newcastle) May 2014 2014 Summary Current long-term management following
FREQUENTLY ASKED QUESTIONS ABOUT PERTUSSIS (WHOOPING COUGH) What is pertussis? General Questions About Pertussis Pertussis, or whooping cough, is a contagious illness that is spread when an infected person
Can I have FAITH in this Review? Find Appraise Include Total Heterogeneity Paul Glasziou Centre for Research in Evidence Based Practice Bond University What do you do? For an acutely ill patient, you do
7 Chest Pain History Ian Woolhouse Scenario Mr Davidson a 55 year old gentleman has been presented to the Medical Admissions Unit complaining of chest pain. Take a history from him. Script Hello Mr Davidson?
Dr Arvind Vasudeva Consultant Cardiologist Atrial Fibrillation An update on diagnosis and management Atrial fibrillation (AF) remains the commonest disturbance of cardiac rhythm seen in clinical practice.
Ali A. Kader, S. (2010). Breast cancer awareness for women and men. UCQ Nursing Journal of Academic Writing, Winter 2010, 70 76. BREAST CANCER AWARENESS FOR WOMEN AND MEN by Samar Ali A. Kader Two years
Introduction To Evidence-Based Practice Keith Posley, MD Lauren Maggio, MS (LIS) Goals & Objectives Define Evidence-Based Medicine (EBM) Articulate the four steps of EBP Learn to formulate answerable clinical
Information for you Treatment of venous thrombosis in pregnancy and after birth Published in September 2011 What is venous thrombosis? Thrombosis is a blood clot in a blood vessel (a vein or an artery).
CT SCAN WHAT IS A CT SCAN? (COMPUTERIZED TOMOGRAPHY) A CT scan is an x-ray exam that produces special images of the body. These images define the shape, size, and position of internal body parts allowing
PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf)
MEDICATION GUIDE WELLBUTRIN (WELL byu-trin) (bupropion hydrochloride) Tablets Read this Medication Guide carefully before you start using WELLBUTRIN and each time you get a refill. There may be new information.
Service Notification in response to DHSSPS endorsed NICE Technology Appraisals NICE TA 275: Apixaban for the prevention of stroke and systemic embolism in people with non-valvular atrial fibrillation 1
Which injectable medication should I take for relapsing-remitting multiple sclerosis? A decision aid to discuss options with your doctor This decision aid is for you if you: Have multiple sclerosis Have
Afrezza Page 1 of 6 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Afrezza (human insulin) Prime Therapeutics will review Prior Authorization requests Prior Authorization
Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL 61938 217-238-4495 Pain Questionnaire Date First name Last name Middle initial Date of birth Sex Male Female Height Weight
Lyme Disease Clinical Research Center 2360 W. Joppa Road Joppa Concourse Suite 320 Lutherville, MD 21093 410-616-7596 Telephone 410-616-7595 Fax Please fill out the attached questionnaire and if possible
EUROPEAN COMMISSION ENTERPRISE AND INDUSTRY DIRECTORATE-GENERAL Consumer goods Pharmaceuticals Guidance on Investigational Medicinal Products (IMPs) and other medicinal products used in Clinical Trials
PROTOCOL Clinical and cost-effectiveness of continuous subcutaneous insulin infusion therapy in diabetes. A. This the revised protocol (April 2002) B. Review team Contact for correspondence: Dr Jill Colquitt
Electroconvulsive Therapy - ECT Introduction Electroconvulsive therapy, or ECT, is a safe and effective treatment that may reduce symptoms related to depression or mental illness. During ECT, certain parts
Version History Policy Title Drugs for MS.Drug fact box cannabis extract (Sativex) Version 1.0 Author West Midlands Commissioning Support Unit Publication Date Jan 2013 Review Date Supersedes/New (Further
Influenza (Flu) What is the flu? The flu is an illness caused by flu viruses. The flu may make people cough and have a sore throat and fever. They may also have a runny or stuffy nose, feel tired, have
Markham Stouffville Hospital Adult Diabetes Education Frequently Asked Questions What is diabetes? Diabetes is a disease in which blood glucose levels are above normal. Most of the food we eat is turned
Statistics of Type 2 Diabetes Of the 17 million Americans with diabetes, 90 percent to 95 percent have type 2 diabetes. Of these, half are unaware they have the disease. People with type 2 diabetes often
A WorkLife4You Guide Heart Attack: What You Need to Know What is a Heart Attack? The heart works 24 hours a day, pumping oxygen and nutrient-rich blood to the body. Blood is supplied to the heart through
MODULE 1: ASKING CLINICAL QUESTIONS There are two main types of clinical questions: background questions and foreground questions. Background questions are those which apply to the clinical topic for all
Oxford University Hospitals NHS Trust Department of Neurology Natalizumab (Tysabri) for Multiple Sclerosis Information for patients page 2 What is Natalizumab and what is it used for? Natalizumab is an
SECTION N: MEDICATIONS Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/reentry if less than 7 days) that any type of injection,
1 Nutrition Type 2 Diabetes: A Growing Challenge in the Healthcare Setting NAME OF STUDENT 2 Type 2 Diabetes: A Growing Challenge in the Healthcare Setting Introduction and background of type 2 diabetes:
Is electrotherapy more effective than other physical therapy approaches in reducing pain and disability in adults with supraspinatus tendonitis? Is one modality of electrotherapy more effective than another?
Malaysian Journal of Pharmaceutical Sciences, Vol. 5, No. 1, 19 23 (2007) COST ANALYSIS OF ANTIDIABETIC DRUGS FOR DIABETES MELLITUS OUTPATIENT IN KODYA YOGYAKARTA HOSPITAL TRI MURTI ANDAYANI* AND IKE IMANINGSIH
Chapter 7 Summary and general discussion Summary and general discussion In this thesis, treatment of vitamin K antagonist-associated bleed with prothrombin complex concentrate was addressed. In this we
U.S. Food and Drug Administration Notice: Archived Document The content in this document is provided on the FDA s website for reference purposes only. It was current when produced, but is no longer maintained
Do you have a health question? Speak with a RN for free! Contact a registered nurse any time, day or night, for answers to your health questions. nurses can help when: You re unsure if you need to visit
Breakfast symposium: From hospital to home - the focus on the patient Nadya Hamedi DARZI Fellow UCLPartners and Barts Health NHS Trust in collaboration with North Central London Local Pharmaceutical Committee
A Program for School Nurses to Train School Staff in Epinephrine Administration The Get Trained School Nursing Program was created through an unrestricted grant from Mylan Specialty. The Program is intended
PRIORITY RESEARCH TOPICS Understanding all the issues associated with antimicrobial resistance is probably impossible, but it is clear that there are a number of key issues about which we need more information.
Rivaroxaban to prevent blood clots for patients who have a lower limb plaster cast Information for patients Pharmacy Your doctor has prescribed a tablet called rivaroxaban. This leaflet tells you about
Traditional Chinese For the Patient: Cetuximab Injection Other names: ERBITUX Cetuximab (se tux i mab) is a drug that is used to treat some types of cancer. It is a monoclonal antibody, a type of protein
Hemorrhagic Stroke GENERAL INFORMATION: What is a hemorrhagic stroke? A hemorrhagic stroke happens when a blood vessel in the brain bursts. This may happen if the blood vessel wall is weak, or sometimes
Package leaflet: Information for the patient Bricanyl Tablets 5 mg terbutaline sulfate Read all of this leaflet carefully before you start taking this medicine because it contains important information
Evaluation of Fife- DICE: Type 2 diabetes insulin conversion Article points 1. Fife-DICE is an insulin conversion group education programme. 2. People with greater than 7.5% on maximum oral therapy are
Hormone therapy and breast cancer: conflicting evidence Cindy Farquhar Cochrane Menstrual Disorders and Subfertility Group The world of hormone therapy in the 1990 s Throughout the 1970s, 1980s and 1990s
Medical management of CHF: A New Class of Medication Al Timothy, M.D. Cardiovascular Institute of the South Disclosures Speakers Bureau for Amgen Background Chronic systolic congestive heart failure remains
THE INTERNET STROKE CENTER PRESENTATIONS AND DISCUSSIONS ON STROKE MANAGEMENT Stroke Prevention in Atrial Fibrillation Gregory Albers, M.D. Director Stanford Stroke Center Professor of Neurology and Neurological
British Columbia Pharmacy Association (BCPhA) Clinical Service Proposal Self-Monitoring of Blood Glucose in Type 2 Diabetes Introduction Self-monitoring of blood glucose (SMBG) is in widespread use among
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
All of our publications are available in different languages, larger print, braille (English only), audio tape or another format of your choice. Information for you Tha gach sgrìobhainn againn rim faotainn
Diabetes Definition Diabetes is a chronic (lifelong) disease marked by high levels of sugar in the blood. Causes Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused
PART III: CONSUMER INFORMATION combined hepatitis A (inactivated) and hepatitis B (recombinant) vaccine This leaflet is part III of a three-part "Product Monograph" published when was approved for sale
Population Health Management Program Program (formerly Disease Management) is dedicated to improving our members health and quality of life. Our Population Health Management Programs aim to improve care
For the treatment of patients with multiple myeloma Your treatment calendar for VELCADE (bortezomib) VELCADE (bortezomib) is approved for the treatment of patients with multiple myeloma (a cancer of the
Provision of Intravenous EDTA Chelation as a Complementary and Alternative Medicine Guideline Updated: August 2010 Replaced: November 1998 To serve the public and guide the medical profession EDTA Chelation
Effect of liraglutide on body weight in overweight or obese subjects with type 2 diabetes: SCALE - Diabetes This trial is conducted in Africa, Asia, Europe and the United States of America (USA). The aim
TALLAHASSEE EYE CENTER PATIENT INFORMATION Date: Name: Gender: M / F First MI Last Date of Birth: / / Address: City: State: ZIP: Phone Numbers: Home: Cellular: Work: E-Mail: SS#: - - What is the best way
DIABETES MELLITUS By Tracey Steenkamp Biokineticist at the Institute for Sport Research, University of Pretoria What is Diabetes Diabetes Mellitus (commonly referred to as diabetes ) is a chronic medical
Nalmefene for reducing alcohol consumption in people with alcohol dependence Issued: November 2014 guidance.nice.org.uk/ta325 NICE has accredited the process used by the Centre for Health Technology Evaluation