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Evidence based medicine

Every board needs an AMBrennan. Just one maybe.

If everyone agreed and looked at things in the same way it would all become very boring and although advice to the newly diagnosed is vitally important, it would not interest many members
after a time.

I learn a lot from discussions sparked by AMBrennan''s comments. And I am keeping a scrap book of Grazer's one -line replies.

I hope AMBrennan is learning a few things too.

,
 
if there are going to be any arguments surrounding the use of blood-test strips, the accuracy of the actual meters (or possible lack thereof) should be brought into said argument, right?
 
An in-depth response, then (well done for supporting microfazer's misdirection, by the way):

1) I don't really care about test strips, and this is not a an argument about test strips; I only (unwisely) used them as an example

2) The accuracy of meters is another theoretical argument. If they improve control then their accuracy doesn't really matter; conversely, if they don't improve control then it is entirely irrelevant how accurately they predict lab test results.
 
AMBrennan said:
An in-depth response, then (well done for supporting microfazer's misdirection, by the way):

1) I don't really care about test strips, and this is not a an argument about test strips; I only (unwisely) used them as an example

2) The accuracy of meters is another theoretical argument. If they improve control then their accuracy doesn't really matter; conversely, if they don't improve control then it is entirely irrelevant how accurately they predict lab test results.
Click to expand...

You're not really Sheldon from the Big Bang Theory are you?
 
AMBrennan said:
An in-depth response, then (well done for supporting microfazer's misdirection, by the way):



2) The accuracy of meters is another theoretical argument. If they improve control then their accuracy doesn't really matter; conversely, if they don't improve control then it is entirely irrelevant how accurately they predict lab test results.
Click to expand...

You do realise I was applauding YOU AMBrennan? Totally agree with your point above too.
Self testing of BG and BP is more about identifying trends,
Having lost out on the test strips argument- {dismissing my claims about spikes as demonstrated by the meter} thanks to the consultant, my ridiculous GP Practice now seem unable to grasp this concept regarding my blood pressure tesing. I originally purchased a blood pressure monitor at the behest of the specialist diabetes doctor in another practice. I now have two and use them to check each other.
Although in the past they have both shown as accurate against the practice monitors they are
unable to understand why a difference of a few points is totally irrelevant if all results are
acceptable anyhow.

Its very frustrating - I am sure you feel the same when atempting to keep discussions on track with
illogical and garrulous people such as myself intervening.!
 
Unbeliever said:
Every board needs an AMBrennan. Just one maybe.
Click to expand...


I think its rather a shame that Grant (NewDestinysChild) hasn't commented in the thread :lol:
 
borofergie said:
AMBrennan said:
Good control of your diabetes minimises the risk of complications, but (as I understand it) it will still be higher than the healthy population baseline. No one can say for certain if you will get complications.
Click to expand...

That's interesting AMBrennan, do you have any large scale randomized trials that demonstrate the incidence of complications of people with well controlled T2 diabetes (ie HbA1c <= 5.6%). Or have we lost our faith in evidence based medicine already?

AMBrennan said:
As for when you will need insulin, it would seem that most type 2 patients will need insulin eventually; you will need insulin if or when other medication stops working.
Click to expand...

Ditto.
Click to expand...
(original here)
Firstly, my comment on insulin therapy was based on NICE guidance, I'd suggest that you inform them of any factual errors. I admit that I did, indeed, take their word for it and didn't spend hours looking up relevant statistics.

You are of course quite correct that we lack long-term studies for well controlled type 2 diabetics. We know that diabetics, including type 2 diabetics, have an increased risk of suffering diabetic complications (thus the name).
We know from long term studies (such as UK Prospective Diabetes Study in type 2 patients, and the DCCT/EDIC in type 1 patients) that good control (HbA1C < 7%) reduces the risk of diabetic complications, but that the risk in patients with the best control is still higher than baseline risk.

So yes, we do not have studies for well controlled type 2 diabetic patients, so we estimate based on studies we do have. The default assumption should that the risk is as high as found in the other studies (i.e. no difference in risk when decreasing HbA1c 7% to 5%).

My point, originally, was about not trusting theoretical arguments too much - particularly if you have conflicting evidence - and the need to ensure that medical interventions actually work.
I did not say that we cannot (carefully) extrapolate from data or otherwise speculate.
 
what AM says about Type 1's being at higher risk of complications even if they always have a Hba1c below 7% is true. My DSN who has been in the job 40 years and who is a Type 1 herself from childhood, has seen patients with fantastic Hba1c's all through their diabetic life go on to develop some terrible complications , the flip side being some with poor Hba1c's stay pretty much complication free.
Its the luck of the draw also ,I'm afraid. I figure though if you do get complications ,if you have tried you best to stay as healthy and within range as possible, then it will sit a lot better with you! Just my way of looking at it...and in life there are no guarantee 's with anything...So make the most of it while you can..and don't get bogged down with all the trivial (word removed) :wink:
Sorry don't know if the same applies to well controlled type 2's. Hope it doesn't
 
AMBrennan said:
You are of course quite correct that we lack long-term studies for well controlled type 2 diabetics.
Click to expand...

Thanks for acknowledging that.

AMBrennan said:
We know that diabetics, including type 2 diabetics, have an increased risk of suffering diabetic complications (thus the name).
Click to expand...

We know that some diabetics have an increased risk of diabetic complications. As you note above we don't have any data for well controlled diabetics (HbA1c<=5.6%).

AMBrennan said:
We know from long term studies (such as UK Prospective Diabetes Study in type 2 patients, and the DCCT/EDIC in type 1 patients) that good control (HbA1C < 7%) reduces the risk of diabetic complications, but that the risk in patients with the best control is still higher than baseline risk.
Click to expand...

UKPDS describes good control as a HbA1c of 7%. That's roughly equivalent an average BG of 9.6 mmol/l, with even higher postprandial spikes. That's hardly what any informed T2 diabetic would call good control. All this study shows that outcomes are improved for patients that reduce their BG levels beneath levels that everyone acknowledges are dangerous.

AMBrennan said:
So yes, we do not have studies for well controlled type 2 diabetic patients, so we estimate based on studies we do have. The default assumption should that the risk is as high as found in the other studies (i.e. no difference in risk when decreasing HbA1c 7% to 5%).
Click to expand...

Big default assumption.

AMBrennan said:
My point, originally, was about not trusting theoretical arguments too much - particularly if you have conflicting evidence - and the need to ensure that medical interventions actually work.
I did not say that we cannot (carefully) extrapolate from data or otherwise speculate.
Click to expand...

Careful extrapolation? :shock: I thought you were a numbers man....

You know as well as I do, that there is no such thing as careful extrapolation (especially one based on default assumptions). We've moved from "evidence based" medicine to "voodo magic" in three easy steps here.

Suggesting to a patient that "you will probably get complications, no matter how much you improve your control" is a medical intervention:
"don't test your BG, eat more carbs, get used to the fact you're going to get your feet chopped off no matter what you do."
 
Am I correct in thinking that there have been few long term studies of T2 issues because until quite recently most T2 were no diagnosed until later in life?

In that case AM Brennan may live to see them but I certainly won't.!

I suppose a great deal depends upon the definition of "long term".
 
Big default assumption
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It is better to overestimate the risk and be prepared, rather than to underestimate the risk. People telling him that he'll be fine in 50 years is even more irresponsible (if only because he might get hit by lighting tomorrow) than telling him that his risk is somewhere between baseline and the risk found in the above mentioned studies (which I wouldn't call "voodo [sic] magic")

Suggesting to a patient that "you will probably get complications, no matter how much you improve your control" is a medical intervention:
Click to expand...
In that case we'd need to evaluate whether the intervention works, and not if the statement used in the intervention is true. If telling people "Elvis is alive" cures patients, then who cares if Elvis is really alive?
 
AMBrennan said:
It is better to overestimate the risk and be prepared, rather than to underestimate the risk.
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Is it? Why?

Surely it's better not to speculate (or extrapolate) and tell him what you know, even when the answer is "we don't know". Unless you have some good clinical data on the positive outcomes of deliberately demoralising patients...

AMBrennan said:
People telling him that he'll be fine in 50 years is even more irresponsible (if only because he might get hit by lighting tomorrow) than telling him that his risk is somewhere between baseline and the risk found in the above mentioned studies (which I wouldn't call "voodo [sic] magic")
Click to expand...

You were extrapolating yesterday and now you are interpolating between baseline studies. Which is it?

I'm not suggesting that you tell anyone that "they will be fine in 50 years", I'm saying that you have an obligation to be honest and tell people "I don't know" if you honestly don't have the evidence to answer the question.

AMBrennan said:
In that case we'd need to evaluate whether the intervention works, and not if the statement used in the intervention is true. If telling people "Elvis is alive" cures patients, then who cares if Elvis is really alive?
Click to expand...

No we don't, because telling a patient "you will probably get complications, no matter how much you improve your control" without evidence to support it, sounds suspiciously like therapeutic nihilism, the avoidance of which is an explicit condition of Hippocratic oath:
"I will apply, for the benefit of the sick, all measures required, avoiding those twin traps of overtreatment and therapeutic nihilism"

AMBrennan said:
In that case we'd need to evaluate whether the intervention works, and not if the statement used in the intervention is true.
Click to expand...

Ethics of lying to patients aside, by your own standards, you'd have to have a large scale clinical trial that proves that telling porkies beneficially influences patient outcomes.
 
Thought I'd get a quick non-scientific word in before Sheldon Cooper (sorry, AMBrennan) :lol: returns with more science.
I'm unlikely to live 50 years with type 2 diabetes. But there again, I was 60 when I was diagnosed! One thing's for sure though; I'll live as long as the average non-diabetic of my age. Why? Pure conviction, and an almost religious determination to keep my BGs at near non-diabetic levels (currently probably about 5 to 5.5, next test result due soon!) Figure that a positive view on my life expectancy is likely to give me a better life than a negative one. It's interesting that in life, people often seem to get what they expect to get. Why make yourself ill worrying about things you can't control?
 
"I will apply ,for the benefit of the sick, all measures required, avoiding the twin traps of overtreatment and therapeutic nihilism".

Do they issue occasional reminders? My treatment at the hands of doctors seems to alternate between one or t'other of the twin traps. The happy middle ground is obviously hard to find.

Sorrry for interruping AMBrennan.
 
OT
Borofergie.
Thanks, for the quote. I couldn't understand how Hippocrates knew about nihilism when the concept only dates from the 19C. The modern version oth the oath dates from the the 1960s.
You lean something new every day :)
 
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