1. EBM Screening Questions

2. Aim * How to answer evidence based management questions. * To pass Saudi Board Written Exam Insha Allah All of you.

3. How is the exam ? 1- The questions are usually 3-4 questions. 2-The resident should answer in terms of - Harm and Benefit - Pros And Cons - Guidelines and recommendations

4. How is the marking? 3- The marking of the question will be as follows; >90% : full coverage of evidence from EBM database 80-90% :evidence content is correct but using one EBM database 60-70% : evidence content is correct but no use of EBM database. Incorrect answer will score zero.

5. Important reference to study Evidence based management 1)Cochrane review ; read the summary and Author's conclusion.Easy to reach it without payment by Google search. 2) BMJ clinical evidence needs subscription 3)American Family Physician Journal ;monthly cochrne reviw and BMJ evidence …and this is very important source*** 4)Guidelins for chronic diseases and common diseases 5)USPSTF recommendations 6)Hot Topics 7)Essential evidence (previously info poem)

6. Evidenc Base Manegement Exam Questions 2008 1)Recommendations regarding screening of breast.cancer 2)Pharmacological modalities for smoking.cessation.3) Evidence regarding cranberry in UTI 4)What are the effect of drug treatment in women with premenstrual syndrome… 5) Antiplatelets and anticoagulant in...hypertension.

7. Let us start this EBM Review

8. Screening A)Cancer Screening Colorectal cancer Cervical Cancer. Breast Cancer Prostate Cancer

9. Screening for Colorectal Cancer According to the latest research evidence The USPSTF recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary. Grade: A Recommendation..

10. The USPSTF recommends against routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in an individual patient. Grade; C RecommendationC Recommendation

11. The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years. Grade: D Recommendation.D Recommendation The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer. Grade: I StatementI Statement

12. According to the Cochrane Databse Systematic Reviw Benefits of screening include ; A modest reduction in colorectal cancer mortality. A possible reduction in cancer incidence through the...detection and removal of colorectal adenomas The less invasive surgery that earlier treatment of colorectal cancers may involve. Harmful effects; The psycho-social consequences of receiving a false positive result. The potentially significant complications of colonoscopy or a false-negative result. The possibility of overdiagnosis (leading to unnecessary investigations or treatment).

13. Breast cancer The U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with or without clinical breast examination, every 1-2 years for women aged 40 and older.U.S. Preventive Services Task Force The USPSTF concludes that the evidence is insufficient to recommend for or against routine clinical breast examination (CBE) alone to screen for breast cancer. The USPSTF concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (BSE). breast cancer screening after age 65 reduces mortality at reasonable costs for women without significant comorbidity

14. Prostate cancer The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years. Grade: I Statement.I Statement The USPSTF recommends against screening for prostate cancer in men age 75 years or older. Grade: D Recommendation.D Recommendation

15. Prostate cancer The harms of screening include the discomfort of prostate biopsy and the psychological harm of false-positive test results. Harms of treatment include erectile dysfunction, urinary incontinence, bowel dysfunction, and death. A proportion of those treated, and possibly harmed, would never have developed cancer symptoms during their lifetime. For men younger than age 75 years, evidence is inadequate to determine whether screening improves health outcomes. Therefore, the balance of harms and benefits cannot be determined. For men age 75 years or older and for those whose life expectancy is 10 years or fewer, the incremental benefit from treatment of prostate cancer detected by screening is small to none. Therefore, harms outweigh benefits.

16. Cervical cancer The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix. Grade: A Recommendation.A Recommendation The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer (go to Clinical Considerations). Grade: D Recommendation.Clinical ConsiderationsD Recommendation The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease. Grade: D Recommendation.D Recommendation The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer. Grade: I Statement.I Statement The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (HPV) testing as a primary screening test for cervical cancer. Grade: I recommendation.I recommendation

17. Smoking: The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. Grade: A Recommendation.A Recommendation The USPSTF strongly recommends that clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke. Grade: A Recommendation.A Recommendation The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for tobacco use or interventions to prevent and treat tobacco use and dependence among children or adolescents. Grade: I Statement.I Statement

18. obesity: The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. Grade: B Recommendation.B Recommendation The USPSTF concludes that the evidence is insufficient to recommend for or against the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults. Grade: I Statement.I Statement The USPSTF concludes that the evidence is insufficient to recommend for or against the use of counseling of any intensity and behavioral interventions to promote sustained weight loss in overweight adults. Grade: I Statement.I Statement The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for overweight in children and adolescents as a means to prevent adverse health outcomes. Rating: I RecommendationI Recommendation

19. Osteoprosis The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures.U.S. Preventive Services Task Force There is good evidence that the risk for osteoporosis and fracture increases with age and other factors; bone density measurements accurately predict the risk for fractures in the short-term; treating asymptomatic women with osteoporosis reduces their risk for fracture. The USPSTF concludes that the benefits of screening and treatment are of at least moderate magnitude for women at increased risk by virtue of age or presence of other risk factors. There is insufficient evidence to recommend for or against routine osteoporosis screening in postmenopausal women who are younger than 60 OR in women aged 60-64 who are not at increased risk for osteoporotic fractures.

20. D.M. Universal screening: According to the American Diabetic association Guideline The effectiveness of early identification of pre- diabetes and diabetes through mass testing of asymptomatic individuals has not been definitively proven (and rigorous trials to provide such proof are unlikely to occur)

21. The argument for screening is Important public health problem D.M is common Impose significant public health burdens. There is a long presymptomatic phase before the diagnosis of type 2 diabetes is usually made. Relatively simple tests are available to detect preclinical disease The duration of glycemic burden is a strong predictor of adverse outcomes, Effective interventions exist to prevent progression of pre-diabetes to diabetes and to reduce risk of complications of diabetes according g to the DCCT and UKDPS (i.e. fulfill many of Wilson and Jungr’s criteria)

22. Argument against this are Community screening outside a health care setting is not recommended because ; People with positive tests may not seek, or have access to, appropriate follow-up testing and care. Conversely, there may be failure to ensure appropriate repeat testing for individuals who test negative. Community screening may also be poorly targeted, i.e., it may fail to reach the groups most at risk and inappropriately test those at low risk (the worried well) or even those already diagnosed. ….

23. Because of the need for follow-up and discussion of abnormal results, testing should be carried out within the health care setting. And to target those at risk according to ADA recommendations …

24. Dyslipedimia Screening Men The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders. Grade: A Recommendation.A Recommendation The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. Grade: B Recommendation.B Recommendation Screening Women at Increased Risk The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. Grade: A Recommendation.A Recommendation The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. Grade: B Recommendation.B Recommendation Screening Young Men and All Women Not at Increased Risk The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, OR in women aged 20 and older who are NOT at increased risk for coronary heart disease. Grade: C Recommendation.C Recommendation

25. HTN The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults age 18 years and older. This is a grade A recommendation.