EBM Exercise 1

1. You are a family physician. A 60 year old man with diabetes comes to your clinic. He
has renal failure. He heard from a friend that one of the medications he is currently
taking Glucophage is “bad” for the kidney and asks your opinion regarding this.
Population: Men of ages 60 and above whom suffer from diabetes who also take
Glucophage as treatment for the diabetes.
Exposure: Treatment with Glucophage/Metformin.
Comparator: A group of 60+ year old men whom suffer from diabetes and DO NOT take
Glucophage/Metformin
Outcome: Damage to the kidneys.
Type of Article best used to answer this question: Prospective Study, Systemic Review of
Prospective study or a Systemic Review article which includes both RCT’s and
prospective studies.
Article Used:
Huang, W., Castelino, R.L. and Peterson, G.M. (2014), Metformin usage in T2DM. Intern Med
J, 44: 266-272. https://doi-org.rproxy.tau.ac.il/10.1111/imj.12369
Answer: Metformin has been found to cause kidney damage in those already suffering
from some sort of kidney damage. The effects of Glucophage on patients without
any renal damage should be investigated.
Pico Question In Article:
In patients with type 2 diabetes (P), what prescribing patterns of Metformin (I) should be
given to the patients (C = diabetes patients who mis-dose Metformin) and can it
potentially cause Renal Impairment (O)
 2. You are a neurologist in the ward. During morning rounds you meet a 65 year old
man after a stroke. He was taking aspirin when the event occurred and asks you if
there is any thing that can be added in order to prevent another event. Clopidogrel?
Population = 65 Year old men who suffered a stroke while on aspirin and are eligible for
Clopidogrel (Plavix) on top of the aspirin.
Intervention = Clopidogrel (Plavix).
Comparator = Current standard of care for men who have suffered strokes in Israel.
Outcome = Another Event.
Type of Article best used to investigate the PICO question: RCT (or a Systemic Review
including RCT’s)
Article Used:
Croke L. Dual Antiplatelet Therapy for High-Risk TIA and Minor Stroke: BMJ Rapid Recommendation.
Am Fam Physician. 2019 Sep 15;100(6):378-379. PMID: 31524354.

Answer: for patients who have suffered a stroke, low dose Aspirin (~300 mg) and a Loading
dose of Clopidogrel should be administered ASAP to combat a recurring event. After 10 to
21 days, the patient should be switched to a single antiplatelet drug and not be
administered with both Aspirin and Clopidogrel. The study (which included 3 RCT’s)
identified that dual therapy decreased nonfatal recurrent strokes.
PICO Question In Article:
Will patients who have already suffered a stroke (P) benefit from the use of dual antiplatelet
therapy (Aspirin + Clopidogrel) (I) as opposed to people who undergo mono antiplatelet
therapy (C) as to recurring strokes (O)
 3. You are a gerontologist a 80 year old man comes to your clinic. He feels that his
memory is deteriorating and asks if any type of cognitive training may help.
Population: Elderly whom suffer from deteriorating memory and are eligible for
cognitive training.
Intervention: Cognitive Training
Comparator: Elderly people with deteriorating memory who don’t conduct cognitive
training as therapy.
Outcome: Memory Retention
Type of Article best used to investigate the PICO question: RCT (or a Systemic Review
including RCT’s)
Article Used:
Yang HL, Chu H, Kao CC, Chiu HL, Tseng IJ, Tseng P, Chou KR. Development and effectiveness
of virtual interactive working memory training for older people with mild cognitive
impairment: a single-blind randomised controlled trial. Age Ageing. 2019 Jul 1;48(4):519-
525. doi: 10.1093/ageing/afz029. PMID: 30989165.
Answer: Older adults who suffer from mild cognitive impairment who undergo virtual
interactive working memory training benefit from the training itself and are shown to be
able to maintain their working memory while reducing the rate of cognitive deterioration.
Thus, Virtual Interactive Working Memory Training should be considered as a therapy to
help combat deteriorating memory.
PICO Question In Article:
Older adults who suffer from mild cognitive impairment (P) who undergo virtual interactive
working memory training (I) are compared to a control group (C) as to memory retention
abilities and rate of memory deterioration (O)
 4. You are a ICU physician with the recent Corona virus pandemic you are debating
whether addition of steroids in individuals with respiratory distress may be beneficial
Population: Individuals with respiratory distress who are eligible for a steroid based therapy
on top of their current therapy.
Intervention: Steroids.
C: Individuals with respiratory distress who are currently on the gold standard treatment for
Respiratory Distress.
O: Mortality from respiratory distress.
Type of Article best used to investigate the PICO question: Randomized controlled trials
(RCT’s) of steroid treatment for ARDS
Article Used:
Adhikari N, Burns KE, Meade MO. Pharmacologic therapies for adults with acute lung injury
and acute respiratory distress syndrome. Cochrane Database Syst Rev. 2004 Oct
18;2004(4):CD004477. doi: 10.1002/14651858.CD004477.pub2. Update in: Cochrane
Database Syst Rev. 2019 Jul 23;7:CD004477. PMID: 15495113; PMCID: PMC6517021.
Answer: Corticosteroids given for late phase ARDS reduced hospital mortality (24 patients;
RR 0.20, 95% CI 0.05 to 0.81) and pentoxifylline (a drug which compliments different types
of steroids) reduced one-month mortality (RR 0.67, 95% CI 0.47 to 0.95) in 30 patients with
metastatic cancer and ARDS. Even though treatment of corticosteroids has been shown to
reduce mortality from ARDS, the results are insignificant. Further study is necessary.
PICO Question In Article:
Do Adults who suffer from ALI or ARDS (P) benefit from different pharmacological
treatments (I) as opposed to ARDS/ALI patients who are not eligible for such treatments
(due to contraindications) (C) and do they show a reduction in mortality rates (O)?
 5. You are a internist in the ward and treating a 70 year old man with
hypertension treated with ACE inhibitors and recently infected by Corona
virus. You are debating if to continue this medication.
Population: Elderly who suffer from hypertension, who have been infected by the Corona
Virus.
Exposure ACEi medication.
Comparator: Hypertensive elderly who have been infected by the Corona Virus and are not
taking ACEi medication.
Outome: mortality rates
Type of article best used to answer this question: Prospective Study, Systemic Review of
Prospective Studies or a Systemic Review article which includes both RCT’s and prospective
studies
Article Used:
Aronson J K, Ferner R E. Drugs and the renin-angiotensin system in covid-
19 BMJ 2020; 369 :m1313 doi:10.1136/bmj.m1313

Answer: Patients who are already taking ACE-1 inhibitors or ARBs have generally been
advised to continue taking their medicines. The Council on Hypertension of the European
Society of Cardiology has highlighted the lack of any evidence to support a harmful effect of
ACE-1 inhibitors and ARBs in the context of the pandemic COVID-19 outbreak; however,
lack of evidence does not demonstrate that the supposed benefit will outweigh the
potential harms in infected patients. The American College of Cardiology has stated that In
the event patients with CVD are diagnosed with the Corona Virus - treatment decisions
should be made according to each patient’s hemodynamic status and clinical presentation.
Also, the effects of using ACEi medication has not been researched enough as to answer the
question of “will the medication help fight an infection by Covid19”.
PICO Question In Article:
Will patients who suffer from a SARS-CoV-2 infection (P) benefit from treatment of ACE-1
Inhibitors (such as Enalapril or Ramipril) (E) as opposed to other conventional treatments of
the disease (C), and will the ACEi treatment help in preventing and treating the effects of
the Corona Virus (O)?
 6. You are an ICU physician with the recent Corona virus pandemic you are debating
what would be the optimal breathing parameters to be used in Corona patients
intubated because of ARDS.
Population: Corona patients intubated because of ARDS.
Intervention: Optimal breathing parameters to diagnose severity of ARDS.
Comparator: gold standard test of estimating ARDS severity in Corona patients (Physical
Exam, Chest X-Ray and O2 Levels)
Outcome: ARDS related mortality in the future or ARDS assessed in any different way.
Type of article best used to answer this PICO question would be: RCT’s (Diagnostic Test VS.
No Diagnostic Test) and Observational Study comparing the current gold standard of
diagnosing ARDS severity to the new optimal breathing parameters found in this article.
Article Used:

Antoniou KM, Vasarmidi E, Russell A-M, et al. European Respiratory Society Statement on
Long COVID-19 Follow-Up. Eur Respir J 2022; in press
(https://doi.org/10.1183/13993003.02174-2021).
Answer: The main parameter used to determine the existence of obstructive patterns of the
lung is the ratio of Forced Expiratory Volume in one second over Forced Vital Capacity
𝑭𝑭𝑭𝑭𝑽𝑽 𝐹𝐹𝐹𝐹𝑉𝑉1
( 𝑭𝑭𝑭𝑭𝑭𝑭𝟏𝟏). Furthermore, reduction of the Total Lung Capacity (TLC) and a low ratio of (when
𝐹𝐹𝐹𝐹𝐹𝐹
TLC could not be measured) have been correlated with respiratory distress. In some studies,
a reduction in Residual Volume of the lung (RV) has also been shown as a pattern of
respiratory distress.
This systemic review has compared the use of breathing parameters above as a mean of
diagnosing respiratory distress as opposed to the diagnosis of respiratory distress while
using tests like physical exercise, 6 minute walking test and cardiopulmonary testing. Using
the breathing patterns found above have been shown to be a useful way of diagnosing
respiratory distress by MOST investigators in the systemic review, and thus are viable
options of diagnosis of ARDS.
PICO Question in article: How do we define (I) the lasting effects of COVID-19 (O) in patients
who have been affected by COVID-19 (P) as opposed to the current “no established
nomenclature” definition (C)?